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SOCIAL  ASPECTS  OF  THE  TREATMENT 
OF  THE  INSANE 

Based  on  a  Study  of  New  York  Experience 


JACOB  A.  GOLDBERG,  A.  M. 


SUBMITTED  IN  PARTIAL  FULFILMENT  OF  THE  REQUIREMENTS 

FOR  THE  DEGREE  OF  DOCTOR  OF  PHILOSOPHY 

IN  THE 

Faculty  of  Political  Science 
Columbia  University 


NEW  YORK 
I92I 


So 

My  Teachers  and  Friends 
STEPHEN  S.  WISE 

AND 

SIDNEY  E.  GOLDSTEIN 


<^  -ili^GSGG 


PREFACE 

The  aim  in  writing  this  volume  was  to  supply  a  needed 
source  to  which  the  layman,  the  social  worker,  the  general 
practitioner,  and  others  could  refer  when  considering  mat- 
ters pertaining  to  the  treatment  of  the  insane.  Many  books 
have  been  written  on  various  phases  of  the  problem,  but, 
no  one  of  these  books  answers  the  purpose  in  mind.  When 
the  writer  first  became  interested  in  mental  hygiene  activi- 
ties, he  sought  in  vain  for  any  one  volume  or  even  for 
several  which  would  give  him  a  comprehensive  understand- 
ing of  the  questions  involved  in  caring  for  and  treating  the 
insane.  The  facts  and  their  interpretations,  as  presented  in 
the  following  pages,  are  the  result  of  several  years  of  active 
and  intensive  work  and  study  of  matters  relating  to  the  in- 
sane. The  reason  so  much  emphasis  has  been  placed  upon 
insanity  among  the  Jews  is  that  the  material  available  to  the 
writer  dealt  largely  with  this  group. 

In  making  a  study  of  this  kind,  the  cooperation  of  many 
persons  is  necessary.  The  thanks  of  the  writer  are  ex- 
tended to  Dr.  M.  B.  Heyman,  Supt.  of  Manhattan  State 
Hospital,  and  to  Dr.  G.  A.  Smith,  Supt.  of  Central  Islip 
State  Hospital,  for  permission  to  consult  records  in  their 
files ;  and  to  Dr.  M.  S.  Gregory,  Director  Psychopathic  Ser- 
vice, Bellevue  Hospital,  for  similar  cooperation.  For  many 
valuable  suggestions  I  am  indebted,  among  others,  to  Drs. 
J.  Smith  and  M.  M.  Sherman,  psychiatrists  of  the  Free 
Synagogue  Mental  Hygiene  Clinics;  tO'  Dr.  A.  A.  Brill,  Dr. 
Bernard  Glueck,  Dr.  H.  M.  Pollock,  Mr.  G.  H.  Hastings, 
149]  7 


8  PREFACE  [150 

and  particularly  to  Profs.  Franklin  H.  Giddings  and  Henry 
R,  Seager. 

I  am  above  all  indebted  to  Prof.  Samuel  McCune  Lindsay, 
who  has  been  my  guide  and  friend  during  the  years  I  have 
studied  at  Columbia  University,  and  to  Dr.  Sidney  E.  Gold- 
stein, teacher  and  friend  for  many  years. 

Jacob  A.  Goldberg 
Columbia  University,  Jan.  21,  1921. 


TABLE  OF  CONTENTS 


PAGE 

CHAPTER  I 

History  of  New  York's  Policy  of  Caring  for  the  Insane 

Introduction 15 

Care  and  Treatment  under  Commonwealth  of   New   York, 

1777  to  1827 16 

1830  to  1873 ig 

1873  to  1888 26 

County  Care  of  Insane •  .   .  28 

State  Care,  1889  to  1920 , 30 

Reception  or  Psychopathic  Hospitals 38 

Hospital  Development  Commission 44 

CHAPTER  II 
Insanity  as  a  Community  Problem 

Cases  Studied 48 

Incidence  of  Insanity  among  Jews 48 

In  European  Countries 48 

Insanity  in  Rural  and  Urban  Districts 50 

Jewish  Insane  in  New  York  City 52 

Methods  of  Committing  Patients  to  State  Hospitals 54 

Legal  Provisions  for  Commitment 54 

Social  Workers  and  Commitment  of  Patients 57 

The  Police  and  Mental  Cases 58 

Definition  of  the  term  "Insanity" 60 

Causes  of  Insanity 62 

Heredity 63 

Alcohol 66 

Syphilis 68 

Injuries  and  Other  Causes 69 

Contributing  Causes 69 

Classification  of  Mental  Diseases 69 

Marital  Condition  of  Admissions  to  Bellevue  Hospital,  Psychopathic 

Wards 94 

Nativity 96 

Age  Distribution 98 

Deportation  of  Immigrant  Insane 99 

151]  9 


10  TABLE  OF  CONTENTS  [152 


PAGE 


Years  Resident  in  United  States loi 

New  Immigration  Law  and  Insanity loi 

Disposition  of  Patients 103 

Mental  Examination  of  Prisoners 106 

Mental  Deficiency  Law 107 

Discharges  from  Psychopathic  Wards 108 

Deaths  in  Psychopathic  Wards 109 

Summary no 

CHAPTER  III 
Results  of  State  Hospital  Care  and  Treatment 

Need  and  Provisions  for  Scientific  Study  of  Insanity in 

Overcrowding  in  State  Hospitals 114 

Extension  of  Observation  Period I  IS 

Private  Sanatoria  and  Hospitals 119 

Classification  of  Patients  at  State  Hospitals 120 

Occupational  Therapy  at  State  Hospitals 121 

Readmissions  to  State  Hospitals 126 

High  Readmission  Rates  among  Jewish  Patients 128 

Reasons  for  High  Readmission  Rates .       130 

Movemtnts  for  Establishment  of  Jewish  Psychopathic  Hospitals  .  132 

Diagnosis  of  Admissions  to  State  Hospitals 133 

Result  of  One  Year  of  State  Hospital  Care 134 

Follow-up  Work  in  New  York  City I37 

Need  for  This  Form  of  Service 137 

Extent  of  Follow-up  Work  in  New  York 138 

Need  for  Follow-up  of  Jewish  Patients 139 

Deaths  in  State  Hospitals 140 

Death  Rate  of  Jewish  Patients 140 

Reasons  for  Increasing  Death  Rates 141 

Length  of  Stay  in  the  Hospitals 143 

CHAPTER  IV 
A  Social  Survbv  of  786  Admissions  to  State  Hospitals 

Introduction ^49 

The  Family  of  the  Insane  Patient 150 

Single  Persons,  without  Dependents,  in  State  Hospitals,  for  One 

Year ^5i 

Value  of  Visits  to  Patients IS3 

Attitude  of  Patients'  Relatives  toward  State  Hospitals IS4 

Married,  Widowed,  and  Divorced  Persons,  without   Dependents, 

Remaining  in  State  Hospitals ISS 

Social  Status  of  Patients  who  Died  in  State  Hospitals 155 


153]  TABLE  OF  CONTENTS  II 

PAGE 

Single 156 

Married 157 

Status  of  Family  Following  Death  of  Husband 158 

Status  of  Family  Following  Death  of  Wife 159 

Social  Problems  Following  Death  of  Married  Patients 160 

Death  of  Aged  Married  Men 161 

Care  of  Dependent  Widows  and  Orphans 161 

Family  Problems  Following  Death  of  Mothers 165 

Widowed 167 

Divorced 168 

Modification  of  Marriage  and  Divorce  Laws 168 

Parole  System  of  State  Hospitals 169 

Development  of  Out-Patient  Departments 169 

Extent  and  Effectiveness  of  Parole  System 170 

Paroled  and  Discharged  Patients 173 

Details  of  Survey  Form 174 

Survey  of  Paroled  and  Discharged  Patients 177 

Mental  Condition 178 

Physical  Condition l8o 

Social  Condition 182 

Employment  of  Paroled  Patients 182 

Financial  Relief  to  Families  of  Patients 184 

Dependent  Children  Committed  to  Orphan  Asylums 185 

Recreational  Opportunities 186 

CHAPTER  V 
Social  Trbatmekt  of  the  Insane 

Introduction 188 

Development  of  Mental  Hygiene  Movement 189 

Organization  and  Development  of  a  Mental  Hygiene  Agency  .   .  191 

Activities  of  a  Mental  Hygiene  Agency 193 

Typical  Cases  of  a  Mental  Hygiene  Agency 195 

Cases  Studied 196 

Manic  Depressive  Insanity 196 

Dementia  Praecox 205 

Paranoid  Condition 214 

General  Paralysis 219 

Arteriosclerosis 220 

Mental  Deficiency 220 

Hysteria 221 

Constitutional  Psychopathic  Inferiority 223 

Total  Presentation  of  Twenty-Five  Typical  Cases 226 


12  TABLE  OF  CONTENTS  [154 

PAGE 

CHAPTER  VI 

Recommendations  and  Conclusion 

Shortcomings  of  Social  Service 228 

Need  of  a  Newer  Method  of  Approach  to  Problem 229 

Mental  Hygiene  and  Childhood 230 

Mental  Hygiene  and  Adolescence 232 

Mental  Hygiene  Needs  of  a  Community 235 

Mental  Hygiene  Agencies 236 

Convalescent  Homes 236 

Clinics 236 

Workshop  for  Mental  Hygiene  Patients 237 

Psychopathic  Hospital 239 

Conclusion 240 


LIST  OF  TABLES 


FAGB 

1.  Total  Admissions  to  Psychopathic  Wards,  New  York  City  .   .  54 

2.  Number  of  Cases  of  Alcoholic  Insanity 67 

3.  Psychoses  of  Admissions 71 

4.  Age  Distribution  :  General  Paralysis 75 

5.  Disposition  of  Manic  Depressive  Insanity  Patients 83 

6.  Age  Distribution  of  Manic  Depressive  Insanity  Patients  ...  84 

7.  Disposition  of  Cases  of  Dementia  Praecox 88 

8.  Age  Distribution  of  Dementia  Praecox  Patients 88 

9.  Number  of   Admissions  to  Bellevue    Hospital,  Psychopathic 

Wards 93 

10.  Marital  Condition 95 

11.  Nativity 97 

12.  Age  Distribution 99 

13.  Years  in  United  States loi 

14.  Disposition  of  Patients 104 

15.  Diagnosis  of  Prisoners 106 

16.  Diagnosis  of  Discharges 109 

17.  Diagnosis  of  Deaths no 

18.  Overcrowding  in  the  State  Hospitals 114 

19.  Number  of  Days  Spent  in  Psychopathic  Wards  of  Bellevue  Hos- 

pital Prior  to  Commitment  to  State  Hospital 117 

20.  Occupations  of  Males 123 

21.  Occupations  of  Females 124 

22.  Number  of  Readmissions  to  State  Hospitals 127 

23.  Distribution  of  Certain  Psychoses  Among  Readmissions  .   .   .  129 

24.  Disposition  of  Patients  by  State  Hospitals 134 

35.  Rate  of  Recovery  and  Improvement  of  Patients 135 

26.  Diagnosis  of  Patients  who  Died  in  State  Hospitals 143 

27.  Duration  of  Hospital  Life  of  Recovered  Cases 144 

28.  Duration  of    Hospital  Life  of  Improved  and  Much  Improved 

Cases 145 

29.  Duration  of  Hospital  Life  of  Patients  Dying  in  State  Hospitals  147 

155]  13 


CHAPTER  I 

History  of  New  York's  Policy' of  Caring  for 
THE  Insane 

I.    INTRODUCTION 

The  gradual  process  of  evolution  in  methods  of  caring 
for  the  insane  may  be  roughly  divided  into  four  periods,^ 
viz : 

1.  The  era  of  demoniacal  exorcism,  or  of  revenge. 

2.  The  chain  and  dungeon  period,  or  of  indifference. 

3.  The  era  of  asylums  for  the  insane,  or  of  humanitarian- 
ism  and  empirical  treatment. 

4.  The  era  of  hospitals  planned  and  organized  to  meet 
the  needs  of  the  various  classes  of  the  insane,  including 
psychopathic  hospitals  for  the  acutely  insane  in  cities, 
and  colonies  for  the  chronic  and  mixed  classes  of  in- 
sane in  the  country;  or  of  scientific  study,  rational 
treatment  and  preventive  medicine.^ 

These  periods,  while  distinct  in  their  outline,  have  not 
shown  any  sudden  'break  of  continuity  in  the  transition  from 
one  period  to  the  other.  It  is  difficult,  therefore,  to  fix  the 
time  limits  of  these  eras  by  centuries,  and  yet  we  may  ap- 
proximate  an  historical  sequence  by  assigning  the  era  of 
demoniacal  exorcism  to  the  Middle  Ages,  the  chain  and  dun- 
geon era  to  the  17th  and  18th  centuries-,  and  the  era  of 
special  asylums  to  the  19th  century,  while  we  reserve  for  the 

1  Peterson,  Frederick,  American  Journal  of  Insanity,  vol.  Iviii,  Nov. 
3,  1902,  p.  405. 

'  Van  Gieson,  Ira,  National  Conference  of  Charities  and  Correction, 
jgoi,  "  Public  Policy  in  the  Care  of  the  Insane,"  p.  161. 

157I  ^5 


l6       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [158 

20th  century  the  distinction  of  introducing  more  generally 
into  modern  civilization  the  methods  of  care  and  treatment 
based  upon  scientific  study,  rational  treatment  and,  above 
all,  preventive  medicine. 

The  aim  of  this  study  being  limited  to  a  consideration  of 
the  genesis  and  development  of  methods  in  the  social  care 
and  treatment  of  the  insane  in  New  York  State,  and  of 
the  social  aspects  of  the  problem,  it  is  obvious  that  a 
discussion  of  the  era  of  revenge  and  of  the  chain  and 
dungeon  period  would  be  largely  out  of  place. 

II.    CARE  AND  TREATMENT 

(a)  Under  Commonwealth  of  New  York,  1777-1821. 
The  first  public  hospital  or  asylum  in  the  State  of  New 
York,  in  which  the  insane  received  special  medical  treat- 
ment, was  the  New  York  City  Hospital.  This  institution 
was  incorporated  by  royal  charter  bearing  date  June  13, 
1771,^  and  a  building  in  pursuance  of  its  objects  was  begun 
in  1773,  which,  unfortunately,  was  destroyed  by  fire  before 
completion.  The  intervention  of  the  Revolutionary  War, 
bringing  with  it  financial  embarrassments,  delayed  the  prog- 
ress O'f  the  work  of  contruction,  so  that,  despite  pecuniary 
aid  received  from  the  colonial  legislature,  the  edifice  was 
not  opened  until  January,  1791.  It  was  then  opened  as  a 
general  hospital,  receiving  all  cases  of  disease  indiscrimin- 
ately, and  in  this  way  cases  of  insanity  gradually  found  their 
way  into  it.^  The  exact  date  of  the  reception  of  the  first 
case  cannot  be  ascertained,  although  two  are  reported  as 
admitted  in  May,    1797.^     Hitherto  the  insane  had  been 

*  Peterson,  Arthur  E.,  anid  Edwards,  Geo.  W.,  New  York  as  an 
Eighteenth  Century  Municipality,  p.  301. 

*  Ordronaux,  John,  Lunacy  Laws  of  New  York,  p.  199. 

*  Earle,  Pliny,  History  of  the  Bloomingdale  Asylum  for  the  Insane, 
1848,  p.  8. 


159]  HISTORY  OF  NEW  YORK'S  POLICY  17 

legally  classified  among  disorderly  persons/  and  were  to  be 
disposed  of  according  to  the  pleasure  of  the  magistrates  be- 
fore whom  they  were  brought,  either  by  being  confined,  or 
if  strangers,  returned  to  their  last  legal  place  of  settlement. 

Meanwhile,  as  the  insane  had  greatly  multiplied  in  num- 
bers, and  formed  an  exceptional  class  whose  condition  re- 
quired for  its  successful  treatment  such  space  and  isolation 
as  could  not  be  obtained  in  a  general  hospital,  the  governors 
of  the  New  York  Hospital  applied  to  the  legislattlre  for 
assistance  to  enable  them  to  build  a  separate  structure  for 
this  class  of  patients.  This  was  granted  themi  in  i8o6,' 
through  the  enactment  of  "  An  Act  for  the  'better  and  more 
permanent  support  of  the  hospital  in  the  City  of  New 
York."  It  provided  that  the  State  of  New  York  should  ap- 
propriate the  sum  of  $12,500  annually  for  a  period  of  fifty 
years  as  a  subsidy  to  the  hospital.  The  new  structure  was 
opened  in  July,  1808.^  No  requirements  were  stipulated 
at  this  time  as  to  the  admission  of  insane  patients,  but  in 
1809  a  law  was  passed,  granting  authority  to  the  overseers 
of  the  poor  of  any  city  or  town  in  the  state  to  contract  with 
the  governors  of  the  New  York  Hospital  for  the  mainten- 
ance and  care  of  any  lunatics  chargeable  to  such  city  or 
town.*  This  act  was  the  initial  step  taken  by  the  legislature 
in  the  recognition  of  the  insane  as  a  special  class  of  diseased 
persons,  requiring  medical  care  and  treatment  in  institutions 
of  a  definite  character.  It  also  established  the  principle  of 
its  judicial  custody  over  them  as  wards,  to  be  protected  and 
supervised  in  their  persons  as  well  as  in  their  estates  through 
the  agency  of  its  courts  and  appointed  officers. 

At  this  period  there  was  no  institution  to  which  the 

*  Laws  of  1788,  chap.  31. 
'  Laws  of  1806,  chap.  54. 

^  Ordronaux,  op.  cit.,  p.  200. 

*  Laws  of  1809,  chap.  90,  sec.  3. 


1 8  SOCIAL  ASPECTS  OF  TREA TMENT  OF  INSANE       [  1 60 

criminal  insane  could  be  sent,  and  two  cases  arose  requiring 
the  action  of  the  legislature,  the  governor  not  being  at 
that  time  empowered  to  grant  pardons  in  such  cases.  In 
1799  one  John  Pastano  was  convicted  of  murder  and  sen- 
tenced to  be  executed.  It  transpired  that  the  man  was  in- 
sane. An  appeal  was  made  to  the  legislature  to  save  him  and 
a  law  was  passed  pardoning  him,  on  condition  that  he  be 
kept  in  prison  until  he  could  be  returned  to  his  place  of  legal 
residence.^  A  similar  case  arose  again  in  181 6  and  was 
disposed  of  in  the  same  way,  except  that  arrangements  were 
to  be  made  by  the  friends  or  relatives  for  care  in  some 
"  lunatic  hospital  or  asylum."  ^  In  181 6  the  society  of  the 
New  York  Hospital  was  again  given  authority  by  law  to 
erect  a  new  building.  This  was  opened  for  use  June,  1821, 
as  the  Bloomingdale  Asylum  for  the  accommodation  of  in- 
sane persons,  and  received  a  further  annuity  of  $10,000,  to 
be  continued  like  the  other  to  1866.^ 

There  was  no  further  legislation  dealing  with  the  com- 
mitment and  care  of  the  insane  until  1827,  when  a  law  was 
passed  bearing  upon  the  proper  provision  for  the  custody 
of  insane  persons  in  jails,  and  the  responsibility  of  the  next 
of  kin  to  care  for  or  make  proper  provision  for  the  care  of 
insane  persons.*     It  might  be  well  to  note  at  this  point  that 

^ Laws  of  1800,  chap.  3,  entitled  "An  Act  to  pardon  John  Pastano 
for  murder." 
^  Laws  of  1816,  chap,  4. 
3  Ibid.,  chap.  203. 

*  Laws  of  1827,  chap.  294,  entitled  An  Art  concerning  Lunatics.  Sees.. 
2,  3  and  4  recite  that  "  no  lunatic  shall  be  confined'  in  any  prison,  gaol 
or  house  of  correction,  or  Ibe  confined  in  the  same  room  with  any 
person  charged  with,  or  convicted  of,  any  criminal  offense.  But  he 
shall  be  sent  to  the  asylum  in  New  York,  or  to  the  County  poor-house 
or  almshouse,  or  other  place  provided  for  the  reception  of  lunatics  by 
the  county  superintendents." 

Sec.  5  recites  that  it  shall  be  the  duty  of  the  parents  or  relatives  of 
any  lunatic,  if  able,  to  support  him  in  such  asylum. 


l6l]  HISTORY  OF  NEW  YORK'S  POLICY  jg 

during  the  first  half-century  of  the  existence  of  the  com- 
monwealth, viz.,  from  1777  to  the  passage  of  the  above  law 
in  1827,  the  insane  were  treated  as  dangerous  persons,  and 
the  policy  was  to  protect  society  against  their  acts  of  violence 
by  arresting  and  incarcerating  them  in  jails  and  prisons  with 
criminals/  For  nearly  twenty  years,  viz.,  from  1808  to 
1827,  the  State  of  Nev^r  York  confined  its  insane  in  jails, 
where  they  were  still  treated  as  criminals  and  were  gienerally 
chained,  as  directed  by  the  law  of  1788;"  in  the  poor- 
houses  or  almshouses,  where  the  chronic  insane  congregated 
and  were  subjected  to  every  possible  degree  of  cruelty  and 
neglect;  and  in  the  asylum  of  the  New  York  Hospital, 
where  they  were  treated  in  the  most  humane  manner,  by 
the  best  class  of  officers  and  attendants.^  It  was  during  the 
next  half  century,  from  1827  tO'  1877,  that  the  policy  of  the 
state  was  steadily  in  the  direction  of  improving  the  public 
care  of  the  insane,  and  especially  of  insane  poor. 

(b)  iSjo-iS/j.  There  was  a  great  want  felt  at  this 
time  for  state  asylums  for  the  insane.  The  population  of 
the  state  had  grown  to  almost  2,000,000  and  there  were  as 
yet  no  special  facilities  provided  by  the  state  or  county 
authorities  for  the  care  of  the  insane,  other  than  what  has 
been  alluded  to  in  regard  to  the  New  York  Hospital.  The 
need  had  become  so  great  that  Gov.  Throop,  in  his  annual 
message  to  the  legislature  of  January,  1830,  called  its  atten- 
tion to  the  uncared-for  condition  of  the  poor  and  indigent 
insane.  He  referred  to  the  privations  and  neglect  to  which 
these  persons  were  subjected  under  poor-house  regulations, 
and  remarked  that  "  no  restoration  can  be  hoped  for  under 
such    circumstances."  *      Moved    by    these    unanswerable 

*  American  Journal  of  Insanity,  July,  1883,  pp.  50-51. 

*  Laws  of  1788,  chap.  31,  sec.  6. 

*  Ani^r.  Jour,  of  In^.,  July,  1886,  pp.  61-62. 

*  Assembly  Document  no.  2,  Jan.  7,  1830.  [ 


20      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [162 

arguments  in  favor  of  state  intervention,  the  assembly 
shortly  thereafter  adopted  a  resolution  that  "  the  standing 
committee  on  charitable  institutions  do  inquire  into  the  pro- 
priety of  making  further  provision  for  ameliorating  the  con- 
dition of  the  insane  poor."  ^  Upon  the  recommendation  of 
this  committee,  there  was  appointed  a  special  committee  to 
investigate  the  manner  in  w^hich  the  hospital  in  the  city  of 
New  York  and  the  asylums  connected  with  it,  had  disbursed 
the  funds  received  from  the  state,  and  to  inquire  into  the 
necessity  of  erecting  a  new  establishmient.^ 

The  report  of  this  special  committee  made  March  10, 
1831,^  dealt  with  the  causation  of  insanity,  its  status  in  this 
and  other  countries,  the  needs  of  the  insane  in  the  state,  and 
the  duty  of  the  state  toward  them.  According  to  this  re- 
port, there  were  at  that  time  (1830)  2,695  insane  persons, 
with  but  one  incorporated  asylum  at  Bloomingdale,  contain- 
ing provision  for  about  200  patients,  and  one  private  asylum 
at  Hudson  with  accommodations  for  50  patients.  It  was 
optional  for  the  Bloomingdale  Asylum  under  the  law  of 
March  24,  1807,  to  accept  pauper  patients,  and  for  this 
reason  there  was  no  provision  whatever  in  the  state  for  the 
comfortable  support  and  proper  treatment  of  the  insane 
poor. 

During  the  session  of  183 1  a  special  legislative  committee 
was  again  appointed  upon  this  subject  and  a  report  sub- 
mitted; but  no  legislative  action  was  taken.  In  the  same 
session  (1831)  Dr.  Samuel  White,  superintendent  of  the 
Hudson  Lunatic  Asylum,  applied  for  a  subsidy  in  aid  of  his 
institution.*  A  special  committee  on  Lunacy  Legislation 
spoke  very  highly  of  the  Hudson  Asylum,  and  recommended 

*  Assembly  Journal,  Jan.  29,  1830. 

*  Assembly  Document  no.  408,  April  14,  1830. 
3  Ibid.,  263,  March  10,  1831. 

*  Ibid.,  305,  April  4,  1831. 


163]  HISTORY  OF  NEW  YORK'S  POLICY  2 1 

that  county  authorities  make  contracts  with  Dr.  White  for 
the  care  of  the  insane  but  did  not  advise  any  subsidy  on  the 
part  of  the  state/ 

In  1832  Gov.  Throop  in  his  annual  message  again  reverted 
to  the  condition  of  the  pauper  insane  as  one  calling  for  state 
intervention.-  A  special  comlmiittee  was  again  appointed 
and  reported  in  favor  of  making  state  provision  for  the  in- 
sane.^ However,  no  action  was  taken  before  the  legislature 
adjourned. 

In  January  1834,  Gov.  Marcy  recalled  the  matter  to  the 
notice  of  the  legislature.*  A  special  committee  was  again 
appointed;  belief  in  state  provision  for  the  insane  was 
reaffirmed,  but  no  legislation  followed.^ 

In  1835  the  same  program  was  essentially  repeated,  with 
the  same  result.^  No  action  was  taken  by  the  legislature  to 
mitigate  the  existing  evils  until  1836,  when  an  act  was  pas- 
sed authorizing  the  establishment  of  the  State  Lunatic 
Asylum  at  Utica.^  This  came  about  at  this  time  largely  as 
a  result  of  a  memorial  presented  toi  the  legislature  by  the 
State  Medical  Society,  asking  for  the  erection  of  a  suitable 
state  asylum  for  the  insane.®  The  asylum  at  Utica  was 
opened  in  1843  s-'^d  was  to  provide  for  the  transfer  of  the 
most  suitable  cases  from  the  county  poor-houses.  In  1850 
the  law  governing  admission  tO'  the  State  Lunatic  Asylum 

1  Assembly  Document  305,  April  i,  1831. 

*  Ibid.,  2,  Jan.  3,  1832. 
''Ibid.,  174,  Feb.  28,  1832. 
*Ibid.,  3,  Jan.  7,  1834. 

^  Ibid.,  347,  March  29,  1834. 
^  Ibid.,  167,  Jan.  31,  1835. 

''Laws  of  1836,  chap.  82,  entitled  An  Act  to  authorize  the  establish- 
ment of  the  New  York  State  Lunatic  Asylum. 

*  2Slh  Annual  Report,  Managers  of   State  Lunatic  Asylum  at  Utica, 
1867,  pp.  50-51. 


22       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [164 

was  amended  so  as  to  restrict  the  selection  of  cases,  by  pro- 
viding that  *'  no  person  in  indigent  circumstances,  not  a 
pauper,  shall  be  admitted  into  the  asylum,  unless  such  per- 
son shall  have  become  insane  within  one  year  next  preced- 
ing such  admission,  and  county  judge  must  take  proof  of 
same."  ^  County  judges  had  the  power  to  send  indigent 
insane  persons  brought  before  them  either  to  the  county 
poor-house  or  the  State  Asylum,  as  in  their  judgment  might 
be  for  the  l>est  interests  of  all  concerned.  The  county 
superintendents  of  the  poor  committed  the  pauper  class. 

It  was  not  until  1848  that  provision  was  made  for  insane 
criminals,  when  an  act  to  amend  the  law  regulating  county 
and  state  prisons  was  passed,  providing  that  whenever  any 
convict  became  insane,  he  was,  after  examination  by  the 
prison  inspector,  to  be  transferred  to  the  Utica  Asylum. - 
If  at  the  expiration  of  his  sentence  he  was  still  insane,  the 
superintendent  of  the  asylum  might  return  him  to  the  charge 
of  the  superintendent  of  the  county  whence  he  came.  As 
a  result  of  the  steady  increase  in  the  number  of  insane  dis- 
covered among  criminals  in  the  prisons,^  and  of  the  impos- 
sibility of  affording  them  suitable  treatment  in  the  hospitals 
attached  to  such  institutions,  further  legislation  was  enacted 
in  1855.  This  represented  the  first  effort  toward  a  more 
systematic  classification  of  the  insane,  and  toward  the  es- 
tablishment of  a  distinction  between  criminals  and  non- 
criminals  in  relation  to  their  detention  in  asylums.*  It 
being  found  impracticable  to  carry  this  project  into 
operation,  and  as  nothing  short  of  a  separate  institution 
would  suffice  for  the  contemplated  purposes,  the  legislature 

'  Laws  of  1850,  chap.  282,  sec.  2. 
*  Lazvs  of  1848,  chap.  294,  sec.  96. 
^  Ordronaux,  op.  cit.,  p.  29. 

*Laws  of   1855,  chap.  456,   entitled  An  Act  to  Provide  for  Insane 
Criminals. 


165]  HISTORY  OF  NEW  YORK'S  POLICY  23 

passed  an  act  organizing  a  special  asylum  in  1858/  The 
institution  thus  erected  at  Auburn  for  the  care  of  insane  con- 
victs provided  accommodations  for  all  the  criminal  insane 
of  the  state  until  1892,  when  the  Matteawan  institution  wasi 
opened  at  Fishkill-on-the-Hudson  (now  Beacon). 

Reference  should  be  made  to  the  care  of  the  insane  in 
the  metropolitan  district — the  counties  of  New  York  and 
Kings — where  the  insane  in  custody  of  the  poor  authorities, 
increased  to  such  an  extent  that  the  almshouse  and  its  at- 
tached hospital,  both  situated  on  the  grounds  of  the  present 
Bellevue  Hospital,  were  unable  to  care  properly  for  those 
under  their  care.  It  was  not  until  1839,  when  the  insane 
asylum  on  Blackwell's  Island  was  opened,  that  any  relief 
was  afforded.  This  was  the  first  institution  of  its  kind 
erected  by  the  County  of  New  York,  and  on  June  10,  1839, 
197  insane  persons  were  removed  to  it  from  the  almshouse 
and  hospital."  From)  time  to  time  additions  were  made  to 
the  Blackwell's  Island  institution  until  1869,  when  the* 
authorities  sought  permission  from  the  legislature  to  issue 
bonds  for  the  purpose  of  laising  funds  to  construct  a  new 
insane  asylum  on  Ward's  Island.^  This  permission  was 
granted  and  the  new  institution  was  opened  in  1871  for 
male  patients  removed  from  Blackwell's  Island,  the  latter 
being  retained  for  women. 

Pauper  lunatics  in  Kings  County,  as  in  other  counties,  had 
been  kept  in  the  poor-house  asylum  on  the  county  farm  at 
Flatbush.     In  1844  the  need  of  better  accommodations  for 

^  Latvs  of  1858,  chap.  130,  entitled  An  Act  to  Organize  the  State 
Lunatic  Asylum  for  Insane  Convicts,  sec.  i  providing  that  "  The  build- 
ing now  being  erected  on  the  prison  grounds  at  Auburn  shall  be  known 
and  designated  as  the  State  Lunatic  Asylum  for  Insane  Convicts." 

*Oirdronaux,  op.  cit.,  pp.  202-203. 

'  Laws  of  1869,  chap.  56,  sec.  i. 


24      SOCIAL  ASPECTS  OF  TREA TMENT  OF  INSANE       [  1 66 

this  increasing  class  led  to  the  passage  of  a  law  ^  which 
authorized  the  county  treasurer  to  raise  funds  to  erect  a 
new  insane  asylum  at  Flatbush.  The  need  of  additional  ac- 
commodations led  to  further  enabling  legislation  in  1851,^ 
1853,^  1855/  1860,^  and  1867.®  Accommodations  were 
thus  provided  for  about  600  patients. 

Like  New  York  and  Kings,  Monroe  County  was  author- 
ized in  1863  to  provide  for  all  its  dependent  insane  and 
construct  a  separate  and  distinct  institution  from  that  of 
the  county  poor-house,  to  be  known  as  the  Monroe  County 
Asylum  at  Rochester/  Of  the  other  coimties  in  the  state, 
not  one  made  adequate  provision  for  their  own  insane. 
There  was  an  increasing  disposition  on  the  part  of  the  coun- 
ties to  resume  the  care  of  their  chronic  insane,  in  many 
instances,  an  assumption  also  of  the  right  of  treating  acute 
cases  of  insanity.  This  was  done  by  coimty  ofHcers  who,  on 
the  plea  of  economy,  evaded  the  law  relating  to  the  speedy 
commitment  of  recent  cases  to  state  asylums,  and  thus  con- 
verted the  poor-house  asylums  into- institutions  for  the  insane.* 

Despite  the  establishment  of  the  State  Asylum  at  Utica, 
the  number  of  insane  in  almshouses  increased  steadily,  due 
to  the  rapid  increase  in  the  population  of  the  state.  In  1855 
the  county  superintendents  of  the  poor  held  a  convention  at 
the  Utica  State  Asylum  in  order  tO'  consider  what  action 
they  should  take  to  remedy  the  difficulties  they  were  having 
in  providing  for  their  insane.    Their  recommendations  were 

^  Laivs  of  1844,  chap.  203. 

*  Lazi's  of  1851,  chap.  351. 
^  Laws  of  1853,  chap.  255. 

*  Laws  of  1855,  chap.  92. 

^  Laivs  of  i860,  chap.  221. 

*  Laws  of  1867,  chap.  546. 

'  Laivs  of  1863,  chap.  82,  sees.  1-9  inc. 

*  Ordronaux,  op.  cist.,  p.  215. 


167]  HISTORY  OF  NEW  YORK'S  POLICY  2$ 

that  two  additional  state  institutions  should  be  contructed. 
At  the  following  session  of  the  legislature  a  bill  was  in- 
troduced creating  two  more  asylums;  it  was  favorably  re- 
ported, but  the  premature  adjournment  of  the  legislature 
arrested  its  further  progress/  At  last,  mainly  through  the 
efforts  of  Miss  Dorothea  L.  Dix  and  Dr.  Sylvester  D.  Wil- 
lard,  secretary  of  the  State  Medical  Society,  the  legislature 
in  1864  authorized  an  investigation  by  Dr.  Willard  of  the 
condition  of  the  insane  in  the  state."  The  report  was  sub- 
mitted to  the  legislature  in  1865  and  dealt  at  some  length 
with  the  appalling  condition  of  the  insane  in  the  county  in- 
stitutions, and  the  crowded  condition  of  the  state  asylum.^ 
The  result  of  the  report  was  the  establishment  of  the  Willard 
Asylum  for  the  insane  poor  O'f  the  chronic  classes,*  and  the 
further  provision  that  acute  cases  were  to  be  sent  tO'  the 
Utica  State  Hospital.  After  the  completion  of  the  Willard 
Asylum  no  more  chronic  cases  were  to-  be  sent  to  the 
county  poor-houses  from  the  Utica  institution,  but  tO'  the 
Willard  Asylum  instead.  The  creation  of  the  distinction 
between  acute  and  chronic  cases  persisted  until  it  was  finally 
abolished  by  the  State  Care  Act  of  1890. 

Further  steps  leading  to  the  establishment  of  other 
asylums  were  being  taken,  and  in  1867  a  law  was  passed 
authorizing  the  establishment  of  the  Hudson  River  Asylum 
at  Poughkeepsie.^  This  institution  was  opened  in  1871  for 
the  reception  of  the  so-called  acute  cases.     In  1870  a  law 

'  Hiird,  Henry  W.,  Instilutional  Care  of  the  Insane,  vol.  iii,  p.  no. 

'  Lazvs  of  1864,  chap.  418,  entitled  An  Act  in  relation  to  insane  per- 
sons in  poor-houses,  insane  asylums  and  other  institutions  in  the  State 
of  New  York,  the  purpose  of  which  was  to  obtain  statistics  of  the 
insane. 

^Assembly  Doc,  vol.  xix,  Session  of  1865. 

*  Laws  of  1865,  chap.  342. 

s  Laws  of  1867,  chap.  93. 


26      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [i68 

was  passed  establishing  a  homeopathic  asylum  at  Middle- 
town,  New  York/  this  being  the  first  attempt  in  the  United 
States  to  establish  such  a  hospital.  It  was  erected  with  the 
aid  of  private  contributions,  and  received  its  first  patients  in 
1874.  An  act  to  establish  the  Buffalo  State  Asylum  for  the 
Insane  was  passed  in  April,  1870."  This  institution  was  of- 
ficially opened  in  November,  1880. 

(c)  181^-1888.  A  turning  point  in  the  history  of  lunacy 
affairs  in  New  York  came  as  the  result  of  the  passage  of  a 
law  in  1873,  whereby  the  office  of  the  State  Commissioner  in 
Lunacy  was  created.^  This  law  also  required  that  private 
asylums  be  licensed.*  It  was  the  duty  of  the  Commissioner 
in  Lunacy  to  examine  into  the  condition  of  the  insane  and 
idiotic,  the  management  and  conduct  of  the  asylums  and 
other  institutions  for  their  custody,^  and  to  submit  a  report 
to  the  State  Board  of  Charities. 

Chapter  571,  Laws  of  1873,  was  found  to  impose  ex- 
ceedingly cumbrous  and  confused  powers  upon  the  Com- 
missioner in  Lunacy.  Among  other  things,  although  he 
was  a  state  official,  instead  of  reporting  his  official  acts  to 
the  legislature,  he  was  required  to  render  a  report  to  the 
State  Board  of  Charities,  at  whose  direction  only  such  re- 
ports could  reach  the  law-making  power.     Furthermore,  in 

*  Laws  of  1870,  chap.  474. 
^  Ibid.,  cihap.  378. 

*  Laws  of  1873,  chap.  571,  entitled  An  Act  further  to  define  the 
powers  and  duties  of  the  Board  of  State  Commissioners  of  Public 
Charities,  and  to  change  the  name  of  the  Board  io  the  State  Board  of 
Charities.  Sec.  13  created  the  oflfke  of  State  Commissioner  in  Lunacy. 
John  Ordronaux,  LL.D.,  professor  of  medical  jurisprudence  in  the  Law 
School  of  Columbia  College,  was  appointed  to  the  office. 

^  Laws  of  1873,  chap.  571,  sec.  9,  requiring  that  private  asylums  be 
licensed  by  the  newly  created  State  Board  of  Charities. 
'"  Lazvs  of  1873,  chap.  571,  sec.  14. 


169]  HISTORY  OF  NEW  YORK'S  POLICY  27 

spite  of  the  fact  that  the  office  had  been  estabhshed  to  dis- 
cover and  redress  wrongs  committed  in  asylums,  no  method 
was  provided  to  do  this,  as  reports  had  to  be  submitted,  as 
above  noted  in  a  round-about  and  time-consuming  manner. 
These  facts  soon  became  so  obvious  that  the  next  legislature 
radically  altered  the  powers  and  duties  of  the  Commissioner 
in  Lunacy.^  This  was  done  by  the  enactment  of  a  law  in 
1874,^  based  upon  recommendations  made  by  the  Commis- 
sioner in  Lunacy,  John  Ordronaux,  and  the  Attorney- 
General,  Daniel  Pratt."     Section  i  of  this  law  provided  that 

no  person  should  be  committed  to  or  confined  as  a  patient  in 
any  asylum  public  or  private,  or  in  any  institution,  home  or 
retreat  for  the  care  and  treatment  of  the  insane,  except  upon 
the  certificate  of  two  physicians,  under  oath,  setting  forth  the 
insanity  of  such  person.  But  no  person  should  be  held  in 
confinement  in  any  such  asylum  for  more  than  five  days,  unless 
within  that  time  such  certificate  be  approved  by  the  judge  or 
justice  of  a  court  of  record  of  the  county  or  district  in  which 
the  alleged  lunatic  resides;  and  said  judge  or  justice  may  in- 
stitute inquiry  and  take  proofs  as  to  any  alleged  lunacy,  before 
approving  or  disapproving  of  such  certificate,  and  may,  in  his 
discretion,  call  a  jury  in  each  case  to  determine  the  question 
of  lunacy. 

Section  2  required  that  "  the  examining  physicians  be  of  re- 
putable character,  graduates  of  some  incorporated  medical 
college,  permanent  residents  of  the  state  and  engaged  in  the 
actual  practice  of  their  profession  for  at  least  three  years," 
and  such  qualifications  had  to  be  certified  to  by  a  judge  of  a 
court  of  record.  Section  3  prohibited  any  physicians  from 
certifying  to  the  insanity  of  any  person  for  the  purpose  of 

^  Laws  of  1874,  chap.  446. 
*  Ibid. 

'  Report  on  a  codification  of  the  Laws  relating  to  the  Insane,  with 
proposed  amendments  thereto,  Senate  Doc.  86,  Session  1874. 


2S       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [170 

committing  him  to  an  asylum  of  which  the  said  physician 
was  either  superintendent,  proprietor,  an  officer,  or  a  regular 
professional  attendant  therein. 

Previously,  county  judges  or  superintendents  of  the  poor 
had  committed  patients  without  the  certificates  of  physi- 
cians, and  up  to  this  time  legislation  had  been  considered 
chiefly  with  a  view  to  protecting  the  public  against  danger- 
ous persons. 

In  order  that  the  Commissioner  in  Lunacy  might  have 
proper  assistance  when  making  any  investigation  intoi  the 
general  management  and  administration  of  any  asylum, 
public  or  private,  in  which  insane  persons  were  detained,  a 
law  was  passed  in  1878,^  providing  that  "  whenever  he  shall 
undertake  any  such  investigation,  he  shall  give  due  notice 
thereof  to  the  district  attorney  of  the  county  in  which  the  in- 
stitution is  located,  and  that  it  shall  be  the  duty  of  such  dis- 
trict attorney  to  appear  at  such  investigation  in  behalf  of  the 
people." 

On  May  13,  1879,  a  law  was  passed  abolishing  the  New 
York  State  Inebriate  Asylum  and  converting  it  into  the 
Binghamton  Asylum  for  the  Chronic  Insane."  The  latter 
was  opened  for  the  reception  of  patients  of  the  chronic 
pauper  class  from  poor-houses  in  October.  1881.  There 
was  no  further  legislation  of  imlj>ortance  until  1887  ^  when 
the  St.  Lawrence  State  Asylum  at  Ogdensburg  was  estab- 
lished. This  institution  was  opened  to  receive  patients  in 
1890. 

III.    COUNTY  CARE  OF  INSANE 

There  were  at  this  time  seven  state  and  three  county 
asylums  for  the  insane.*     Despite  this  fact,  the  number  of 

*  Laivs  of  1878,  chap.  47,  sec.  2. 

*  Laws  of  1879,  chap.  280. 
'  Laws  of  1887,  chap.  375. 

*  State  Commissioner  in  Lunacy,  Annual  Report,  1888,  p.  99. 


lyij  HISTORY  OF  NEW  YORK'S  POLICY  29 

insane  in  almshouses  was  still  as  great  as  in  1869,  when  the 
Willard  Asylum  was  opened.  The  growth  of  the  general 
population  of  the  state,  which  in  1890  reached  almost 
6,000,000/  was  so  great  that  the  state  institutions  were  in- 
adequate to  meet  the  demands  made  upon  them.  In  the 
meantime  the  movement  on  the  part  of  the  county  authori- 
ties, which  had  begun  in  1871,"  for  exemption  from  sending 
chronic  cases  to  the  state  institutions,  was  gradually  ex- 
tended until  in  1887  there  were  19  counties  legally  author- 
ized to  maintain  this  class  of  dependents.  A  further 
indication  of  the  pressure  brought  to  bear  to  bring  about 
the  extension  of  the  system  of  county  care  of  the  insane, 
was  the  Act  passed  in  1888  providing  for  the  support,  con- 
trol and  management  of  the  chronic  insane  in  Erie  County, 
through  the  establishment  of  a  county  institution. ' 

However,  objections  to  the  county  system  were  numerous 
and  of  great  weight.  Its  greatest  fault  was  the  fact  that 
there  was  no  uniformity  in  the  care  bestowed  upon  patients, 
nor  was  there  any  standard  of  care.  Each  county  asylum 
was  managed  by  local  men,  generally  without  experience  or 
adequate  training  and  with  only  a  limited  knowledge  of  the 
requirements  of  such  an  institution.  The  asyhims  were 
not  under  the  control  of  medical  men  and  their  management 
was  apt  to  be  governed  by  considerations  of  economy  rather 
than  of  humanity.  In  consequence  of  these  conditions,  as 
many  systems  of  maiiagiament  were  evolved  as  there  were 

*  U.  S.  Census. 

*  Laws  of  1871,  chap.  713,  entitled  An  Act  in  relation  <to  the  chronic 
pauper  insane,  authorizing  the  State  Board  of  Charities  to  exempt 
counties  from  the  operation  of  section  10  of  the  Willard  Asylum  Act, 
which  required  that  all  the  chronic  pauper  insane  from  the  poor-houses, 
and  all  those  discharged  not  recovered  from  the  State  Lunatic  Asylum, 
should  be  sent  to  the  Willard  Asylum  (Laws  of  1865,  chap.  342). 

'  Laws  of  1888,  chap.  360. 


30      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [172 

counties,  and  the  insane  thus  shehered  failed  to  get  uniform 
care  or  adequate  and  proper  treatment/ 

The  true  state  of  affairs  at  this  time  (1888)  may  be  sur- 
mised from  the  figures  quoted  below,  from  which  it  will  be 
seen  that  the  number  of  insane  patients  outside  of  state  in- 
stitutions was  almost  twice  as  large  as  within  such  institu- 
tions.^ 

The  distribution  of  insane  patients  was  as  follows: 

Number 

State  asylums  for  the  acute  insane 1,808 

State  asylums  for  the  chronic  insane  2,851 

State  asylums  for  insane  criminals  216 

State  asylum  for  insane  emigrants  42 

4,917 

County  asylums  for  acute  and  chronic  insane,  viz : 

New  York  4,439 

Kings    1,531 

Monroe    276 

County  asylums  for  chronic  insane 1,763 

Poor-houses    482 

City  alms-houses   25 

Private  asylums  794 

9,310 


Total    14,227 

IV.    STATE   CARE    {l88p-Ip20) 

The  deplorable  conditions  under  which  many  of  the  insane 
in  the  state  had  to  exist  were  becoming  worse  from  year  to 
year,  due  largely  to  the  rapid  increase  in  the  general  popula- 
tion, and  the  concomitant  increase  in  the  insane  population. 
In  1886,  realizing  that  an  end  to  county  care  of  the  insane 
was  imperative,  especially  from  the  humanitarian  point  of 

'  Hurd,  Itistitutional  Care  of  the  Insane,  vol.  i,  p.  145. 

^  State  Commissioner  in  Lunacy,  Annuai  Report,  1888,  p.  98. 


173]  HISTORY  OF  NEW  YORK'S  POLICY  31 

view,  the  committee  on  the  insane  of  the  State  Charities  Aid 
Association  was  directed  by  a  resolution  of  the  board  of 
managers,  to  report,  in  the  form  of  a  bill,  a  practical  plan 
for  removing  the  dependent  insane  from  the  county 
asylums  and  poor-houses  and  placing  them  under  the  care 
of  the  state/ 

The  State  Medical  Society  joined  the  State  Charities  Aid 
Association  in  the  campaign  for  legislation  to  obliterate 
county  care  entirely  and  succeeded  in  1889  in  obtaining  as 
a  preliminary  step,  the  passage  of  a  law  creating  a  new  State 
Commission  in  Lunacy  of  three  members :  a  physician,  a 
lawyer  and  a  reputable  citizen,  the  medical  member  being 
designated  the  president  of  the  commission."  The  follow- 
ing year  these  same  organizations,  aided  by  the  new  com- 
missioners, were  instrumental  in  getting  the  State  Care  Act 
passed  in  the  face  of  much  opposition  from  supervisors  and 
superintendents  of  the  poor  of  exempted  counties.  This 
act  was  based  upon  a  plan  drawn  up  in  1875  by  the  State 
Charities  Aid  Association.^  The  final  bill,  drafted  by  a 
member  of  the  State  Charities  Aid  Association,^  passed  the 
legislature  without  amendment,  and  came  to  be  known  as  the 
State  Care  Act  of  1890.^     This  law  emlbodied  much  con- 

^  State  iCommissioner  in  Lunacy,  Annual  Report,  1893,  pp.  490-491. 
'  Laws  of  1889,  chap.  283. 

3  State  Charities  Aid  Assn.,  Annual  Report,  1875.  Dr.  C.  R.  Agnew, 
Chairman  of  the  Committee  on  Hospitals,  drew  up  the  plan. 

*  Prof.  Theodore  W.  Dwight,  Dean  of  the  Columbia  Collie  Law 
School,  member  of  the  committee  on  the  insane  of  the  State  Charities 
Aid  Assn. 

*  Laws  of  1890,  chap.  126,  entitled  An  Act  to  promote  the  care  and 
curative  treatment  of  the  pauper  and  indigent  insane  in  'the  counties  of 
this  state,  except  New  York,  Kings  and  Monroe  counties,  and  to  per- 
mit said  excepted  counties  or  either  of  them,  in  accordance  with  the 
action  of  their  respective  local  authorities,  to  avail  themselves  or  anyone 
of  them,  of  the  provisions  of  this  act. 


32      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [174 

tained  in  the  law  creating  the  State  Commissioner  in 
Lunacy/  but  eradicated  completely  county  care,  except  in 
the  case  of  New  York,  Kings  and  Monroe  Counties,  where 
the  asylums  became  state  institutions  within  the  following 
six  years.-  The  existing  state  asylums  were  enlarged  as 
rapidly  as  possible  "  in  order  to  provide  accommodations 
for  about  2,200  additional  patients,^  all  of  whom  were  trans- 
ferred to  state  care  in  the  course  of  two  or  three  years. 

Under  the  provisions  of  the  State  Care  Act.°  the  state  was 
divided  into  as  many  asylum  districts  as  there  were  state 
insane  asylums  in  the  state,  and  provision  was  made  to  either 
change  or  increase  the  districts  as  necessity  demanded.  As 
a  result  of  the  early  experiences  with  the  office  of  State 
Commissioner  in  Lunacy,  the  new  law  gave  the  Commission 
in  Lunacy  adequate  powers,  and  charged  the  commission 
with  the  execution  of  the  provisions  of  the  State  Care  Act, 
conferring  on  it  the  power  tO'  make  such  rulings  concerning 
the  management  of  the  several  institutions  as  in  its  judg- 
ment seemed  desirable  and  necessary. 

The  Commission  in  Lunacy  was  formally  organized  in 
June,  1889,  and  at  once  set  about  the  performance  of  the 
duties  assigned.  The  first  inspection  by  the  commissioners 
of  all  county  asylums  and  poor-houses  of  the  state  convinced 
them  that  exclusive  state  care  was  absolutely  necessary,  and 
the  presentation  of  a  report  to  the  legislature  on  conditions 
as  found  by  them  did  much  to  hasten  the  full  establishment 

^  Laws  of  1874,  chap.  446. 

*  Laws  of  1891,  chap.  335,  entitled  Ati  Act  for  the  conversion  of 
Monroe  County  Insane  Asylum  into  a  state  hospital,  as  provided  in 
Section  14,  Chapter  126,  Laws  of  1890. 

'  Appropriations  for  this  purpose  were  made  to  the  various  state  hos- 
pitals by  Laws  of  1891,  chap.  91. 

*  State  Commission  in  Lunacy,  Annual  Report,  1893,  pp.  5-6. 

*  Laws  of  1890,  chap.  126,  sec.  i. 


1^5]  HISTORY  OF  NEW  YORK'S  POLICY  33 

of  State  care/  The  commission,  even  before  the  enactment 
of  the  State  Care  Act,  had  been  granted  powers  more  ex- 
tensive in  their  scope  and  of  greater  authority  than  those  en- 
joyed by  the  British  Commission  at  that  time.'  Among  the 
immediate  results  of  the  Acts  of  1889  and  1890  was  one 
that  was  not  at  first  contemplated,  namely,  the  removal  to 
state  hospitals  by  certain  non-exempted  counties,  of  the  so- 
called  chronic  insane  who  had  been  kept  in  custody  in  the 
county  poor-houses  in  clear  violation  of  the  law.  Thus 
within  one  year  23  counties  were  entirely  relieved  of  their 
insane;  *  in  1894  Queens  County  abandoned  its  suit  against 
the  state  in  resistance  to  the  requirements  of  the  State  Care 
Act,  and  all  its  insane  remaining  patients  in  the  wretched 
institution  at  Mineola  were  transferred  to  the  Hudson  River 
State  Hospital  at  Poughkeepsie.* 

It  should  be  noted  that  much  of  the  opposition  to  state 
care  for  the  insane  centered  about  the  division  of  the  insane 
by  law  and  practice  into  two  classes,  the  curable  and  the 
incurable.  The  thought  was  that  the  insane  who  were  be- 
lieved to  be  beyond  cure  might  need  less  medical  attend- 
ance, and  less  of  all  other  comforts  and  enjoyments  which 
go  to  make  life  bearable  to  this  unfortunate  class.* 

By  the  year  1895  the  dependent  insane  of  fifty-nine  of  the 
sixty  counties  of  the  state  were  under  state  care  and  treat- 
ment in  state  hospitals.'     Kings  County  was  admitted  by  an 

'  State  Commission  in  Lunacy,  Annual  Report,  1889,  pp.  19-21,  43,  45. 
'  Riggs,  C.  E.,  "  Progress  in  the  Care  of  the  Insane  in  the  last  20 
Years,"  N.  C.  C.  C,  1893. 

*  State  Commission  in  Lunacy,  Annual  Report,  1890,  p.  32. 

*  S.  C.  in  L.,  Annual  Report,  1894,  p.  5. 

^  S.  C.  in  L.,  Annual  Report,  1891,'p.  285. 

*  S.  C.  in  L.,  Annual  Report,  1895,  P-  7- 


34      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [175 

act  of  the  legislature  of  this  year.^  The  attempt  was  made 
in  the  same  year  to  put  New  York  County  under  the  State 
Care  Act  but  the  bill  to  convert  the  New  York  City  Asylums 
into  the  Manhattan  State  Hospitals  failed  to  become  a  law. 
The  authorities  of  New  York  City  at  this  time  began  to 
question  the  constitutionality  of  the  State  Care  Act,  insofar 
as  under  its  provisions  New  York  County  had  to  pay  not 
only  for  the  care  and  maintenance  of  its  own  insane,  but 
also  had  to  contribute  its  share  of  the  state  tax.  It  should 
be  noted  that  the  tax  had  been  paid  for  a  period  of  nearly 
sixty  years.-  However,  the  difficulty  was  solved  and  state 
care  for  all  New  York  State  consummated  by  the  enactment 
of  a  law  in  1896  covering  New  York  County.^ 

The  effect  of  the  enactment  and  practical  application  of 
the  State  Care  Act  in  New  York  was  not  only  felt  through- 
out the  United  States  *  but  influenced  legislation  along 
similar  lines  in  countries  in  America  and  in  Europe.^  The 
energy  of  those  connected  with  the  management  of  the 
state  hospitals  was  fully  occupied,  during  the  first  decade  of 
state  care  (1890-1900),  with  the  completion  of  the  general 
frame-work  of  the  system,  with  bringing  the  great  metro- 
politan hospitals  into  it,  and  with  establishing,  at  least  in 
statutory  fomi,  the  outlines  of  a  coordinated  and  organized 
state  system.     This  accomplished,  the  next  decade  was  de- 

^  Laws  of  1895,  chap.  628,  entitled  An  Act  for  the  transfer  of  the 
grounds,  buildings  and  equipment  of  the  Kings  County  Lunatic  asylums, 
with  their  intnates  to  the  state,  and  for  the  establishment  in  lieu  thereof 
of  the  Long  Island  State  Hospital. 

*  New  York  City  Dept.  of  Public  Charities  and  Corr.,  Annual  Report^ 
1894,  p.  58. 

*  Laws  of  1896,  chap.  2,  entitled  An  Act  for  the  conversion  of  New 
York  City  asylums  for  the  insane  into  a  state  hospital,  and  to  establish 
the  Manhattan  State  Hospital. 

*  Hurd,  op.  cit.,  vol.  i,  p.  324. 

*  State  Com.  in  Lunacy,  Ammal  Report,  1895,  p.  7. 


177]  HISTORY  OF  NEW  YORK'S  POLICY  35 

voted  to  developing  the  smooth  and  efficient  operation  of  all 
of  the  state  hospitals  under  conditions  established  by  the 
new  system.  Due  to  the  large  number  of  insane  cared  for 
in  state  hospitals,  it  has  been  necessary  to  develop  a  system 
of  smooth,  efficient,  and  economical  administration.  It  is 
the  practical  application  of  the  State  Care  Act,  as  well  as  in 
the  act  itself,  that  many  other  states  and  countries  have  been 
interested.^ 

The  benefits  and  achievements  resulting  from  the  enact- 
ment of  the  State  Care  Act  in  1 8go  are  not  only  numerous, 
but,  as  noted  below,  most  important  for  the  proper  care  and 
treatment  of  the  insane: 

Adoption,  on  July  i,  1890,  of  a  new  and  improved  form 
of  medical  certificate  in  lunacy,  designed  to  facilitate  the 
commitment  of  insane  persons  to  institutions,  and  at  the 
same  time  to  provide  the  liberty  of  the  individual  with 
better  safeguards  against  wrongful  intent  than  had  hereto- 
fore existed.^ 

Registration  in  the  office  of  the  commission  of  all  qualified 
medical  examiners  in  lunacy  in  the  state,  thus  enabling  the 
commission  on  receipt  of  a  lunacy  certificate  to  determine 
if  the  examiners  signing  the  same  are  legally  qualified  to 
perform  these  services.^ 

Complete  registration  in  the  office  of  the  commission  O'f  all 
persons  held  in  custody  as  insane,  whether  in  public  or 
private  institutions.* 

Adoption  of  a  uniforim'  system  of  statistical  returns  for  all 
hospitals  and  asylums,  public  and  private.^ 

*  Folks,  Homer,  The  State  Hospitals  at  the  Parting  of  the  Ways,  ad- 
dress at  Buffalo,  N.  Y.,  Sept.  6,  1912,  p.  4. 

*  State  Com.  in  Lunacy,  Annual  Report,  1890,  p.  125. 
'  Ibid.,  p.  124. 

*  Ibid.,  p.  124. 

*  Ibid.,  p.  125. 


36      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [178 

Provision  for  the  transfer  of  patients  from  one  institu- 
tion to  another,  on  the  order  of  the  commission,  whenever 
for  any  sufficient  reasons  this  may  be  deemed  desirabk/ 

Regulation  providing  for  the  admission  of  private  patients 
to  state  hospitals  from  any  part  of  the  state  without  restric- 
tion as  to  district,  at  a  maximum  rate  not  to  exceed 
$10.00  per  week.  The  rights  of  the  other  patients  are 
protected  by  the  provision  that  there  shall  be  no  distinc- 
tion between  public  and  private  patients  in  regard  to  the 
scale  of  care  and  accommodations  furnished  them.^ 

Provision  for  the  paroling  of  patients  who  are  not  re- 
garded as  homicidal,  suicidal,  or  otherwise  dangerous  for  a 
period  of  six  months,  during  any  portion  of  which  they  may 
be  returned  to  the  hospital  without  a  new  process  of  com- 
mitment. This  permits  patients  whose  condition  warrants 
it  to  go  home  on  trial  before  final  discharge.^ 

Change  in  the  legal  title  of  the  state  institutions  from 
asylum  to  hospital.* 

Division  of  state  into  districts  dependent  upon  number  of 
cases  and  accommodations.^ 

^  Recommendation  for  regulation  relating  to  transfer  of  patients  made 
by  Com.  in  Lunacy  in  Annual  Report  of  1889.  State  Care  Act  of  189G 
made  such  provision.  See  State  Com.  in  Lunacy,  Annual  Report,  1893, 
pp.  75-76. 

^  State  Com.  in  Lunacy,  Annual  Report,  1890,  p.  30.  State  Care  Act 
only  contemplated  the  public  or  indigent  insane.  All  pay  patients  were 
absolutely  excluded  from  its  consideration.  This  necessitated  the  issu- 
ance of  the  regulation.  See  State  Com.  in  Lunacy,  Annual  Report, 
1890,  p.  82. 

'State  Com.  in  Lunacy,  Annual  Report,  1890,  p.  163.  Recommenda- 
tion ifirst  made  that  a  law  ibe  enacted  permitting  patients  to  be  dis- 
discharged  on  parole. 

Lazvs  of  1917,  chap.  335,  extended  parole  period  to  not  exceeding 
one  year. 

*  State  Com.  in  Lunacy,  Annual  Report,  1890,  pp.  15-16. 

^  Ibid.,  p.  25. 


179]  HISTORY  OF  NEW  YORK'S  POLICY  37 

Provision  requiring  relatives  who'  are  legally  liable  to  do 
so  to  pay  at  the  rate  of  $10.00  per  week  or  less/ 

Abolition  of  spoils  system  in  appointing  medical  officers 
through  adoption  of  plan  of   civil  service  examinations." 

Maintenance  of  a  training  school  for  nurses  made  obliga- 
tory by  amendment  to  law  in  1895.^ 

Creation  of  a  psychiatric  institute  at  Ward's  Island,  with 
special  courses  of  instruction  for  benefit  of  medical  officers 
at  the  various  hospitals.* 

Appointment  of  a  medical  inspector  to  visit  and  inspect 
the  state  hospitals  and  other  institutions  for  the  insane,  and 
to  examine  all  patients  admitted,  subject  to  the  direction  of 
the  commission.  All  the  state  and  private  institutions  are 
under  the  general  supervision  of  the  commission.^ 

Abolition  of  mechanical  restraint  and  substitution  of 
prolonged  baths  and  occasional  seclusion  for  brief  periods  in 
treatment  of  violent  and  disturbed  patients.® 

Segregation  and  special  treatment  of  tuberculous  insane. '^ 

Establishment  of  a  system  of  after-care  of  the  insane  in 
collaboration  with  the  State  Charities  Aid  Association.* 
At  the  present  time  this  work  is  carried  on  practically  in- 
dependently of  the  association  by  the  State  Hospital  Com- 
mission. 

Establishment  of  a  bureau  of  deportation,  to  return  to 
other  states  and  countries  deportable  cases. ^ 

^  Laws  of  1896,  chap.  545,  sec.  69;  Laws  of  1910,  chap.  389,  sec.  85. 

*  State  Com.  in  Lunacy,  Annual  Report,  iSgo,  pp.  93-94, 
^  Ibid.,  1896,  pp.  124-125. 

*  State  Com.  in  Lunacy,  Annual  Report,  1895,  p.  104;  Annual  Report, 
1896,  pp.  75-79. 

» Ibid. 

*  State  Com.  in  Lunacy,  Annual  Report,  1901,  p.  35. 
'  Ibid. 

*  State  Hospital  Com.  Annual  Report,  1916,  p.  121. 

'  Laws  of  1912,  chap.  121,  sec.  19.  ' 


38      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [i8o 

Change  in  the  name  of  the  State  Lunacy  Commission  to 
the  State  Hospital  Commission.^ 

Promotion  of  the  work  of  the  State  Charities  Aid  As- 
sociation in  opening  cHnics  for  nervous  and  mental  diseases 
in  the  large  centers,  in  cooperation  with  the  imedical  staffs 
of  the  nearest  hospitals.^  Though  the  original  impetus  to 
after-care  and  preventive  work  in  this  state  came  from  the 
State  Charities  Aid  Association,  it  never  established  any 
clinics  of  its  own,  except  in  the  sense  that  the  association 
urged  their  establishment  and  took  some  part  in  the  physical 
arrangement  thereof,  as  well  as  in  the  provision  of  social 
service  workers.  In  the  establishment  and  operation  of  the 
out-patient  departments  of  the  various  state  hospitals,  the 
role  of  the  association  has  been  merely  that  of  an  interested, 
cooperating  outsider. 

V.    RECEPTION  OR  PSYCHOPATHIC  HOSPITALS 

Between  the  years  1880  and  1890,  medical  men  began  to 
realize  that  in  order  to  increase  the  ratio  of  recoveries 
among  insane  persons,  radical  changes  would  have  to  be 
made  in  the  methods  of  treatment,  especially  insofar  as 
acute  cases  were  concerned.  Dr.  Frederick  Peterson,  sub- 
sequently Commissioner  of  Lunacy  in  New  York,  especially 
urged  the  desirability  of  the  erection  of  psychopathic 
hospitals  arranged  for  the  treatment  of  acute  mental  cases.  ^ 
In  1888  the  Commissioner  in  Lunacy  reviewed  the  work  of 
the  pavilion  iov  the  insane  in  Bellevue  Hospital,  New  York 
City,  and  found  that  one- fourth  of  the  persons  admitted  at 
that  time  were  discharged  as  not  insane,  as  they  were,  for 
the  most  part,  persons  addicted  to  the  excessive  use  of  in- 
toxicating liquors  or  drugs.*     This  pavilion,  however,  now 

*  Laws  of  1912,  chap.  121,  sec.  2. 

'  State  Hospital  Com.  Annual  Report,  1916,  pp.  121-122. 

*  Hurd,  op.  cit.,  vol.  i,  p.  258. 

*  State  Commissioner  in  Lunacy,  Annual  Report,  1888,  p.  188. 


l8i]  HISTORY  OF  NEW  YORK'S  POLICY  39 

as  in  1888,  receives  patients  for  observation  only,  in  order 
to  determine  whether  or  not  they  should  be  sent  to  a  state 
hospital. 

The  movement  for  the  establishment  of  reception 
hospitals  and  pavilions  throughout  the  state  continued,  and 
in  1 89 1  the  State  Commission  in  Lunacy,  in  its  report  to 
the  legislature,  recommended  "  that  the  Legislature  require 
counties  (except  New  York)  to  provide  suitable  places  of 
detention  for  j>ersons  pending  examination  as  to  their  in- 
sanity, to  be  known  as  receiving  pavilions."  ^  No  action 
was  taken  at  this  time  nor  for  some  years  thereafter. 

It  was  not  until  1900  that  a  definite  recommendation  for 
the  erection  of  a  reception  hospital  was  made  by  the  State 
Charities  Aid  Association."  The  plan  advocated  provided 
for  the  accommodation  of  600  patients  by  the  erection,  in 
several  of  the  largest  cities  of  the  state,  of  comparatively 
small  reception  or  psychopathic  hospitals  as  branches  of  the 
existing  state  hospitals.  These  new  institutions  were  to  be 
designed  for  the  reception  and  temporary  treatment  of  in- 
sane patients.  The  reception  hospital  for  New  York  City 
was  to  be  a  branch  of  the  Manhattan  State  Hospital  and 
iake  the  place  of  the  wards  for  the  insane  at  Bellevue. 
Furthermore,  the  thought  was  that  these  newer  and  better 
equipped  institutions  should  be  prepared  to  care  for  (i) 
excited  cases,  (2)  restless  and  suicidal  cases,  (3)  quiet 
cases,  (4)  private  or  paying  patients. ^^  The  State  Co-m- 
mission  in  Lunacy  estimated  in  1901  that  such  a  hospital 
on  Manhattan  Island  should  accommodate  from  100  to  200 

^  State  Com.  in  Lunacy,  Annual  Report,  1891,  p.  529. 

'State  Com.  in  Lunacy,  Annual  Report,  1900;  Report  of  State  Char- 
ities Aid  Association,  p.  1054. 

'  Peterson,  Frederick,  "  New  Paths  is  Psychiatry,"  Phila.  Medical 
Journal,  June  11,  1898;  "A  Visit  to  the  Newest  Psychopathic  Hos- 
pital," Medical  News,  Jan.  20,  1900;  "Some  of  the  PTX)blems  of  the 
Alienist,"  American  Journal  of  Ins.,  vol.  Ivi,  no.  i,  1899. 


40      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [182 

patients,  and  a  similar  one  in  Brooklyn  from  50  to  100 
patients/  It  is  quite  obvious  that  because  of  the  large 
increase  in  the  population  of  Greater  New  York  ajid  the 
state  as  a  whole,  these  estimates  would  now  be  too  low. 

Reception  hospitals  in  the  United  States  have  been  in 
operation  for  a  number  of  years  in  Boston,  Baltimore,  and 
Ann  Arbor,  as  well  as  in  Albany,  as  a  part  of  the  general 
hospital.-  For  smaller  cities  and  towns,  these  reception  or 
psychopathic  hospitals  may  properly  become  wards  of  a 
general  hospital.  In  a  large  city  like  New  York,  however, 
with  its  hundreds  of  admissions  to  state  hospitals  every  year, 
a  special  institution  would  have  to  be  created. 

It  is  self-evident  that  the  mentally  sick  should  be  per- 
mitted the  same  rights  of  treatment  for  their  various  illnes- 
ses as  the  physically  sick,  that  they  should  be  accorded  the 
same  consideration,  and  that  the  hospitals  of  the  several  cities 
should  be  prepared  to  receive,  care  for,  and  intelligently 
treat  them.  This  means  that  somewhere  in  a  city  there 
should  be  wards  specially  designed  and  maintained  for  the 
receipt,  care  and  treatment,  of  patients  suffering  from 
mental  diseases.^  Such  wards  or  hospitals,  adequately 
equipped  and  properly  officered,  with  organic  connections 
with  a  large  municipal  or  state  hospital,  would  be  the 
centers  where  all  persons  ailing  mentally  would  receive 
prompt  and  effective  advice  and  treatment,^  and  from  which 
would  radiate  all  efforts  at  popular  instruction  in  matters 

^  State  Com.  in  Lunacy,  Annual  Report,  1901,  p.  31. 

'  Hurd,  op.  cit.,  vol.  i,  pp.  258,  259. 

^  For  results  of  treatment  in  psychopathic  hospital,  see  "Analysis  of 
Recoveries  at  the  Psychopathic  Hospital,  Boston,"  by  Thomas  H» 
Haines,  in  Boston  Medical  and  Surgical  Journal,  Dec.  31,  1914.  Also 
similar  study  by  E.  E.  Southard,  M.D.,  Boston  Medical  and  Surgical 
Journal,  Sept.  24,  1914. 

*  White,  William  A.,  "  Dividing  Line  between  General  Hospital  and 
Hospital  for  the  Insane,"  The  Modern  Hospital,  March  1914."  State 
Com.  in  Lunacy,  Annual  Report,  1902,  pp.  83-84. 


183]  HISTORY  OF  NEW  YORK'S  POLICY  41 

connnected  with  mental  disease.  A  psychopathic  hospital 
or  department,  in  conjunction  with  its  other  functions, 
should  serve  as  a  prophylactic  and  educational  station. 
Standing  in  a  community  on  the  plane  with  the  general 
hospital,  or  other  specialized  hospital,  it  emphasizes  mental 
disease  as  a  disease,  and  should  serve  as  a  center  to  which 
may  come  for  advice  and  counsel,  those  suffering  from 
psychoneuroses  and  the  early  stages  of  mental  disease, 
as  easily  and  freely  as  they  would  seek  out  a  general 
hospital  in  case  of  organic  illness/ 

The  State  Commission  in  Lunacy,  as  well  as  the  State 
Charities  Aid  Association,  both  strongly  advocated  for  a 
number  of  years  the  construction  of  a  series  of  psychopathic 
hospitals  throughout  the  state  for  the  reception  and  treat- 
mient  of  acute  curable  cases.'  In  1902  a  law  was  passed 
providing  that  accommodations  be  obtained  or  provided  for 
the  observation  and  treatment  of  a  limited  number  of  in- 
sane persons.^  A  year  later  a  bill  to  establish  a  reception 
hospital  for  the  insane  was  introduced  in  the  legislature  but 
failed  to  pass.*  The  following  year  (1904)  the  same  bill 
was  introduced  and  was  passed  with  slight  modification.^ 

*  Williams,  Frankwood  E.,  "  Psychopathic  Hospitals  and  Prophy- 
laxis," Boston  Medical  and  Surgical  Journal,  June  24,  1915,  pp.  933,  935. 

*  State  Com.  in  Lunacy,  Annual  Report,  1902,  pp.  7,  1027-1029. 

^  Lazvs  of  1902,  chap.  593,  providing  that  "  The  Commission  shall 
provide  accommodations  in  the  City  of  New  York  for  a  hospital  to 
receive  a  limited  number  of  alleged  insane,  and  insane  persons,  where 
skilled  observation  is  necessary  in  making  required  pathological  and 
psychopathic  research  and  examination.  Admission  to  the  hospital 
hereby  created  shall  be  regulated  by  the  Commission." 

*  State  Com.  in  Lunacy,  Annual  Report,  1903,  p.  956. 

*  Laws  of  1904,  chap.  760,  entitled  An  Act  authorising  the  City  of 
New  York  to  acquire  a  site  and  to  lease  the  sam-e  to  the  state  for  4he 
establishment  thereon  of  a  reception  hospital  for  the  insane.  The  hos- 
pital thus  to  be  erected  was  to  have  accommodations  for  not  less  than 
200  patients,  and  the  sum  of  Three  Hundred  Thousand  Dollars  was 
to  be  spent  for  the  erection  of  the  necessary  buildings. 


42       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [184 

In  1905  an  appropriation  of  $150,000  was  made  by  the 
legislature  toward  the  erection  of  the  hospital/  and  action 
was  taken  to  obtain  cooperation  between  the  State  Com- 
mission in  Lunacy  and  the  New  York  City  authorities." 
A  site  for  the  proposed  psychopathic  or  reception  hospital 
was  finally  acquired  by  the  City  of  New  York,  but  upon 
investigation  by  the  Commission  in  Lunacy  it  was  found 
that  the  site  was  unsuited  for  the  purpose  intended  for  a 
number  of  reasons,  among  them  the  inaccessibility  of  the 
plot,  its  meagre  extent,  and  its  noisy  neighbors.^ 

The  State  Hospital  Commission^  passed  a  resolution  in 
1912  referring  the  consideration  of  the  question  of  the 
pyschopathic  hospital  and  the  site  selected  by  the  city,  to  a 
committee  consisting  of  the  superintendents  of  four  state 
hospitals  in  the  metropolitan  district  and  three  other  mem- 
bers.■"*  At  a  meeting  held  July  24,  1912,  a  decision  was 
reached  to  the  effect  that  "  it  was  the  sense  of  this  committee 
that  the  time  is  not  yet  ripe  for  the  establishment  of  an  in- 
sitution  such  as  proposed,  and  that  therefore,  the  city  be 
notified  that  the  state  is  at  present  unable  to  proceed  with 

*  State  Com.  in  Lunacy,  Annual  Report,  1905,  p.  27. 

*  Ibid.,  pp.  1093-1094. 

*  State  Com.  in  Lunacy,  Annual  Report,  1908,  pp.  65-66.  The  site 
was  situated  between  72<i  and  74th  streets,  near  the  East  River,  a 
neighborhood  far  from  being  suited  for  the  purpose  of  a  psychopathic 
hospital. 

*  Name  of  State  Commission  in  Lunacy  changed  to  State  Hospital 
Commission  by  Lazvs  of  1912,  chap.  121,  sec.  2. 

*  The  full  committee  was  composed  of  Dr.  August  Hoch,  director  of 
the  Psychiatric  Institute,  Wards  Island;  Dr.  William  Mabon,  Supt.  of 
Manhattan  State  Hospital ;  Dr.  G.  A.  Smith,  Supt.  of  Central  Islip 
State  Hospital ;  Dr.  Wm.  A.  iMacey,  Supt.  of  Kings  Park  State  Hos- 
pital; Dr.  E.  M.  Somers,  Supt.  of  Long  Island  State  Hospital,  and  Mr. 
Homer  Folks  of  the  State  Charities  Aid  Association.  (Vide  Annual 
Report,  State  Hospital  Com.,  1912,  p.  84.) 


185]  HISTORY  OF  NEW  YORK'S  POLICY  43 

the  erection  of  a  reception  hospital."  ^  After  further  con- 
sideration of  the  entire  project  by  the  commission,  it  was 
concluded  that  such  an  undertaking  would  not  be  justifiable 
at  the  time,  owing  to  the  large  expenditures  necessary  for 
the  maintenance  of  the  department  as  a  whole.-  Legisla- 
ion  was  enacted  in  191 3  for  the  purpose  of  authorizing  the 
commission,  on  behalf  of  the  state,  to  surrender  to  the  City 
of  New  York  the  indenture  of  lease  for  the  property  lying 
between  73d  and  74th  streets  and  the  East  River. ^  Thus 
ended,  for  the  time  being,  the  attempt  to  secure  a  psychopa- 
thic hospital  for  New  York  City.  It  should  be  noted  that 
the  principle  of  the  necessity  of  such  hospitals  was  sustained, 
but  that,  due  to  the  existing  overcrowding  in  the  metro- 
politan district  hospitals,  relief  in  this  direction  was  con- 
sidered of  paramount  importance,  as  inexpensive  additions 
to  the  then  existing  establishments  were  thought  necessary 
to  bring  about  an  alleviation  of  the  overcrowding.  And 
indeed,  the  hospitals  continue  to  be  overcrowded,*  in  spite  of 
the  fact  that  additions  to  the  existing  institutions  have  been 
built.  Whether  or  not  the  State  Commission  was  right  in 
reversing  its  policy  of  insisting  upon  the  erection  of  a 
psychopathic  hospital  for  New  York  City  may  become 
more  evident  from  what  follows.  Be  that  as  it  may,  an 
institution  for  the  insane  or  mentally  ill,  in  which  all  dis- 
turbing and  distressing  features,  all  confusing  and  fatiguing 
agencies  will  be  prohibited,  is  essential  for  the  cure  and 

*The  only  dissenting  member  was  Mr.  Homer  Folks,  who  was  of 
opinion  that  a  hospital  should  !be  built  (24th  A.  R.,  S.  H.  C,  p.  85). 

»  State  Hospital  Com.,  Annual  Report,  1912-1913,  p.  62. 

'  Laws  of  191 3,  chap.  678. 

*  On  June  30,  1918,  the  13  civil  hospitals,  with  a  capacity  of  28,997, 
housed  35,462  patients,  an  overcrowding  of  6,465  patients,  or  22.3  per 
cent.  The  overcrowding  has  been  around  the  6,000  mark  for  a  number 
of  years.     (35th  A.  R.,  S.  H.  C,  1917-1918,  p.  235.) 


44      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [i86 

relief  of  the  mentally  sick.  Recoveries  of  acute  mental 
cases  depend  to  a  great  extent  upon  the  nature  of  the 
initial  care.  Such  care,  as  described  above,  can  be  given  in 
a  psychopathic  hospital ;  and  the  agitation  for  these  institu- 
tions will  continue  until  efforts  in  this  direction  are  crowned 
with  success. 

VI.    HOSPITAL  DEVELOPMENT  COMMISSION 

The  urgent  necessity  for  relief  of  the  overcrowded  con- 
ditions existing  in  the  state  hospitals  prior  to  1914,  and 
since  aggravated  by  the  war/  became  apparent  to  the  legis- 
lature in  1917,  when  Chapter  238  was  passed.  This  law 
created  the  Hospital  Development  Commission  and  author- 
ized large  expenditures  for  new  buildings."  The  measure  in 
brief  provides  for  a  survey  of  the  state  hospitals  for  the 
insane,  the  development  and  adoption  of  a  plan  to  provide 
for  the  present  surplus  and  the  future  increase  in  the 
patients,  and  directs  the  commission  to  recommend  to  the 
legislature  each  year  the  appropriation  necessary  to  com- 
plete one-tenth  of  the  entire  hospital  development  plan. 
The  measure  also  provides  for  the  investigation  of  the  prob- 
lem of  the  care  oif  the  feeble-minded  and  the  development 
of  a  plan  for  its  solution.^ 

^  During  the  year  1916-1917  only  27  patients  were  deported,  less  than 
7  per  cent  of  the  number  departed  under  normal  conditions.  (29th  A. 
R.,  S.  H.  C,  p.  166.)  During  the  year  1917-1918  the  total  number  of 
aliens  deported  was  53,  as  compared  with  825  in  1914. .  (30th  A.  R., 
S.  H.  C,  p.  77.) 

*  Hospital  Development  Commission  to  consist  of  State  Engineer, 
Chairman  of  State  Hospital  Commission,  State  Architect,  Chairman 
Senate  Finance  Commission,  Chairman  Assembly  Ways  and  Means 
Committee,  two  members  to  be  appointed  by  Governor,  one  member  of 
Legislature,  who  shall  be  a  minority  member  of  one  of  the  finanicial 
committees  of  Legislature,  to  be  named  by  Minority  leaders  of  Senate 
and  Assembly. 

» 29th  A.  R.,  S.  H.  C,  pp.  50-51. 


187]  HISTORY  OF  NEW  YORK'S  POLICY  45 

Shortly  after  the  organization  of  the  commission/  the 
State  Charities  Aid  Association  brought  to  the  attention  of 
the  members  of  the  new  body  the  fact  that  the  establishment 
of  psychopathic  hospitals  is  an  important  part  of  any  com- 
plete program!  for  the  care  and  cure  of  the  insane."  In  its 
report  to  the  legislature  of  February  18,  191 8,  the  Hospital 
Development  Commission  recommended  the  establishment 
of  a  psychiatric  hospital  on  Manhattan  Island,  and  gave  its 
reasons  for  this  action,  outlining  very  briefly  the  nature 
and  purposes  O'f  such  an  institution.^  After  the  submission 
of  this  report  the  Committee  on  Metropolitan  District  of  the 
Comission  continued  its  visits  and  studies  of  all  the  existing 
psychopathic  hospitals  in  the  United  States.  These  con- 
tinued investigations  strengthened  the  committee's  convic- 
tion that  a  psychopathic  hospital  was  urgently  needed  on 
Manhattan  Island  as  part  of  the  state  hospital  system.  The 
committee  prepared  a  report  detailing  plans  which,  in  its 
judgment,  should  be  followed  in  organizing  such  an  institu- 
tion. 

The  purposes  of  the  institution  should  be :  * 

(A)  Treatment — To  reach  persons  suffering  from  men- 
tal disorders  in  their  early  and  often  curable  stages, 
and  lead  them  back  to  mental  health  without  the  sup- 

*  In  the  constitutional  convention  held  in  1915  the  proposal  was  made 
that  a  20-year  program  be  provided  for  the  development  of  the  state 
hospitals,  in  order  to  remove  these  institutions  from  the  field  of  poli- 
tics. (N.  Y.  Constitutional  Convention,  1915,  Revised  Record,  pp.  2883- 
2885.) 

*  Memorandum  submitted  to  the  Hospital  Development  Commission 
by  the  Committee  on  Mental  Hygiene  of  the  State  Charities  Aid  Asso- 
ciation, November  1917.  This  contained  a  concise  and  forceful  state- 
ment of  the  problem  and  ways  of  meeting  it,  etc. 

^  N.  y.  State  Hospital  Quarterly,  August  1918;  Mental  Hygiene, 
Jan.  1919,  p.  113. 

*30th  A.  R.,  ,S.  H.  C,  1917-1918,  pp.  67-71. 


46      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [ i88 

posed  stigma  of  legal  commitment  to  an  asylum 
for  the  insane.  Entrance  to  be  made  easy.  Many 
cases  would  thus  be  saved  from  prolonged  stays  in  a 
state  hospital. 

(B)  Research — To  develop,  through  study  and  research, 
more  and  more  methods,  by  which  mental  maladies 
may  be  prevented  or  recognized  in  their  early 
stages,  and  by  which  they  may  be  successfully 
treated. 

(C)  Teaching — To  endeavor  to  spread  abroad  a  better 
knowledge  and  understanding  of  mental  disorders, 
with  a  view  of  securing  effective  cooperation  in 
coping  with  them 

(D)  Service  to  State  Hospitals — To  serve  as  a  place 
where  each  new  plan  of  treatment  that  is  seriously 
proposed  shall  be  studied  and  tried  out,  with  a  view 
to  its  introduction,  if  found  worthy,  into  the  other 
institutions  of  the  system 

Legislation  seems  to  have  assured  the  eventual  establish- 
ment of  a  state  psychopathic  hospital  in  New  York  City, 
long  advocated  as  an  urgent  need  to  round  out  the  system  of 
state  care  of  the  insane.  The  chief  results  that  may  be 
hoped  for  as  a  result  of  this  legislation  are  as  follows : 

(A)  Such  hospitals  will  help  check  the  present  rapid  in- 
crease in  the  number  of  insane  by  heading  off  the 
stream  at  its  source. 

(B)  Such  hospitals,  by  preventing  and  curing  cases  of 
mental  disease  in  incipient  and  early  stages,  will 
prevent  their  becoming  chronic  insane  patients,  and 
will  save  the  state  the  expense  of  continuous  care 
of  chronic  cases  for  a  long  term  of  years  in  regular 
state  hospitals. 

(C)  These  hospitals,  by  receiving  and  caring  for  recent 


189]  HISTORY  OF  NEW  YORK'S  POLICY  47 

and  acute  cases  of  insanity,  will  diminish  the  num- 
bers annually  committed  to  the  other  state  hos- 
pitals, and  so  will  relieve  tlie  overcrowding  in  these 
hospitals. 

An  expenditure  of  $700,000  was  authorized  by  the  legisla- 
ture in  1920  for  the  construction  of  buildings  and  the  de- 
velopment of  the  grounds  of  the  new  psychopathic  hospital/ 
Plans  have  already  been  drawn  by  the  state  architect  for  a 
state  psychopathic  hospital  in  New  York  City,  for  which 
it  is  hoped  the  city  will  be  persuaded  to  provide  a  site. 
These  plans  have  been  considered  by  the  Hospital  Develop- 
ment Commission  and  are  now  being  studied  by  the  commis- 
sion's medical  committee  and  other  medical  experts.  If 
they  are  approved  by  the  commission,  it  is  likely  that  an 
effort  will  be  made  to  hasten  the  erection  O'f  this  most  im- 
portant adjunct  of  the  state  hospital  system. 

In  the  foregoing  pages  the  attempt  has  been  made  to 
present  an  outline  of  the  most  important  phases  of  legisla- 
tion affecting  the  insane  in  New  York  State,  and  to  lay  the 
backgroimd  and  prepare  the  field  for  a  further  consideration 
of  the  problems  involved  in  dealing  with  this  group  of  the 
state's  charges.  The  following  chapters  will  consider  a 
large  number  of  cases  of  insanity  as  at  present  handled,  and 
will  indicate  the  social  implications  of  the  problem  as  a 
whole. 

^  Laws  of  1920,  chap.  860. 


CHAPTER  II 

Insanity  as  a  Community  Problem 

i.  cases  studied 

The  cosmopolitan  nature  of  the  population  of  New  York 
City  makes  it  the  most  fertile  field  oi  study  for  the  group 
of  cases  under  consideration.  Material  for  both  social  and 
clinical  observation  is  found  here  in  albundance,  and  it  is 
because  of  these  facts  that  this  study  is  limited  to  a  parti- 
cular group  of  cases,  namely,  the  Jewish  patients  admitted 
to  the  psychopathic  or  observation  wards,  male  and  female, 
of  Bellevue  Hospital  during  a  twelve-month  period.  The 
writer  has  had  unusual  opportunities  to  observe  and  work 
with  Jewish  psychopathic  cases  for  several  years  and  it  is 
his  hope  that  out  of  such  studies  and  observations  as  he 
and  others  in  this  field  may  be  able  to  make  and  record, 
methods  in  the  social  care  of  the  insane  may  be  formulated 
and  made  the  basis  of  further  studies,  as  well  as  used  as 
guides  in  the  social  care  of  the  insane,  irrespective  of  race 
or  nationality. 

II.    INCIDENCE  OF  INSANITY  AMONG  JEWS 

(a)  In  European  Countries.  For  years  it  has  been 
maintained  by  the  psychiatrical  world  that  the  Jewish  race 
contributed  more  cases  of  insanity  than  any  other  race.'" 
Of  late  years,  however,  some  investigators  in  this  field  have 

'  Brill,  A.  A.  and  Karpas,  M.  J.,  "  Insanity  among  Jews,"  Medical 
Record,  Oct.  3,  1914,  pp.  576-578. 

48  [190 


IQl]  INSANITY  AS  A  COMMUNITY  PROBLEM  49 

begun  to  doubt  this  traditional  view;  they  have  found  that 
it  was  not  sufficiently  demonstrated  that  the  Jew  differed 
in  his  liability  to  insanity  from  the  Gentile,  and  some  have 
gone  so  far  as  to  assert  that  the  converse  is  true/  This 
conclusion  was  also  reached  a  few  years  ago  by  the  United 
States  Department  of  Commerce  which  stated  in  its  report : 
"  On  the  contrary,  facts  from  which  deductions  can  be 
made  point  rather  to  a  comparatively  smaller  amount  of  in- 
sanity among  Jews  than  among  people  of  several  other 
races."  -  Studies  of  the  incidence  of  insanity  among  Jews 
have  been  made  in  a  number  of  European  countries  where 
these  people  have  lived  for  many  centuries.  Lombroso 
found  that  the  seemingly  larger  percentage  of  insanity 
among  Jews  was  not  so  much  a  matter  of  race  as  of  in- 
tellectual work,  for  among  the  Semitic  races  in  general 
(Arabs,  Bedouins)  insanity  is  very  rare.^  The  results  of 
a  more  recent  study  of  the  problem  as  it  exists  in  Germany 
were  published  in  1909  by  Sichel,  whose  deductions  were 
based  on  careful  investigations  of  the  records  of  the  Frank- 
fort Hospital  for  the  insane.  He  found  that  although  there 
were  relatively  more  Jewish  inmates  than  the  corresponding 
percentage  of  the  Jewish  population  in  Frankfort,  this 
could  only  be  demonstrated  in  reference  to  certain  groups 
of  mental  disorders;  however,  the  other  types  revealed  a 
smaller  percentage  of  Jews  than  of  non-Jews.*  Studies 
by  A.  Pilcz  in  Vienna  and  C.  F.  Beadles  in  London  seem 
to  indicate  a  higher  percentage  of  insanity  among  Jews  than 

1  Brill,  A.  A.,  "  Adfjustmetit  of  the  Jew  to  the  American  Environ- 
ment," Mental  Hygiene,  April,  1918,  pp.  219-220. 

'U.  S.  Dept.  of  Commerce  Report,  quoted  in  Mental  Hygiene,  April 
1918,  p.  219. 

*  Lombroso,  E.,  Crime,  Its  Causes  and  Remedies,  1909,  p.  39. 

*  Sichel,  Max,  Die  Geistesstorungen  bei  den  Juden  (Leipzig,  1909), 
pp.  43-81. 


50      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [192 

among  non-Jews.^  In  this  country  Spitzka,  in  1880,  came 
to  the  conclusion  after  a  careful  study  of  the  problem,  that 
on  the  whole  the  different  forms  of  insanity  occur  in  nearly 
the  same  proportions  in  the  Anglo-Saxon,  Teutonic,  Celtic 
and  Hebrew  races.-  In  considering  the  figures  for  Europe 
it  should  be  remembered  that  in  a  number  of  the  larger 
European  countries  as  late  as  the  nineteenth,  and  in  some 
even  in  tJie  present  century,  Jews  have  been  harassed  and 
forced  to  endure  unusual  stresses  and  strains  and  even  the 
torture  of  violent  death  at  the  hands  of  their  persecutors. 
For  these  reasons  it  would  hardly  be  advisable  for  the  pur- 
poses of  scientific  knowledge  and  accuracy  to  consider 
statistics  gathered  in  such  lands.  The  largest  number  of 
Jews  within  modern  times  congregated  in  a  limited  area  are 
to  be  found  in  New  York  State  and  City;  for  this  reason 
the  admissions  to  the  psychopathic  wards  of  Bellevue  Hos- 
pital, New  York  City,  have  been  made  the  basis  of  the 
statistical  study  of  the  problem  considered  in  this  work. 

(b)  Insanity  in  Rural  and  Urban  Districts.  The  total 
number  of  first  admissions  to  the  civil  state  hospitals  in 
New  York  for  191 7  was  as  follows:  males  3,605;  females 
3,272 ;  total  6,877.  O^  these  398  males  and  402  females, 
a  total  of  800,  were  Jewish,  or  ii.o  per  cent  males  and  12.3 
per  cent  females,  with  a  general  average  of  11.6  per  cent.* 
The  total  state  population  in  19 17  was  9,917,438,*  the  total 
Jewish  population  was  approximxately   1,600,000,^  or   16.0 

'  Jewish  Encyclopedia,  article  "  Insanity,"  vol.  vi,  p.  606. 

'Spitzka,  Edward  C.,  "Race  and  Insanity,"  Journal  for  Nervous 
and  Mental  Diseases,  1880. 

*  State  Hospital  Commission,  29th  Annual  Report,  1916-1917,  p.  426. 

*S.  H.  C,  30th  A.  R.,  1917-1918,  p.  57. 

^Jewish  Communal  Register,  New  York  City,  1917,  p.  89;  Dushkin, 
Alexander  M.,  A  Survey  of  Jewish  Religious  Education  in  New  York 
City,  (Dissertation  Teacher's  College,  Columbia  Univ.,  1918)  in  which 


1 93]  INSANITY  AS  A  COMMUNITY  PROBLEM  51, 

per  cent  of  the  general  population.  In  191 8  the  figures 
were  about  the  same- — total  number  of  first  admissions, 
6,797;  total  number  of  Jewish  patients,  first  admissions, 
832.^  The  figures  indicate  a  much  lower  percentage  of  in- 
sanity among  Jews  in  the  state  than  in  the  remaining  general 
population.  It  should  be  observed  also  that  very  close 
to  100  per  cent  of  the  Jews  in  the  state  live  in  New  York 
City,  only  a  small  proportion  living  in  the  other  cities  in 
the  state,  with  very  few  in  the  rural  districts. 

During  the  year  19 10  the  urban  population  of  the  United 
States  contributed  102.8  admissions  and  the  rural  but  41.4 
admissions  per  100,000  of  tlie  population  to  the  institutions 
for  the  insane  and  feeblemlinded."  An  important  factor 
having  a  bearing  upon  this  question  is  the  difference  between 
the  two  portions  of  the  population  in  age  distribution;  only 
27.2  per  cent  of  the  urban  population  and  as  many  as  36.3 
per  cent  of  the  rural  population  falls  in  the  group  under  15 
years  of  age,  a  group  contributing  but  a  small  fraction  of 
the  admissions  to  institutions  for  the  insane.^  The  marked 
difference  between  urban  and  rural  commitments,  especially 
in  New  York  State,  is  still  further  emphasized  by  the  fact 
that  the  rate  of  first  admissions  per  100,000  population  is 
much  higher  in  the  counties  of  the  state  in  which  cities  are 
located  than  in  those  in  which  there  are  few,  if  any,  cities 
of  considerable  size.  Thus,  the  rate  per  100,000  population 
for  New  York  County  in  191 8  was  105.9,  whereas  it  was 

the  Jewish  population  for  New  York  City  in  1917  is  placed  at  1,500,000. 
Chalmers,  Henry,  "  Jews  in  New  York  City,"  Amer,.  Jour,  of  Statis- 
tics, 1914-191S,  placed  the  Jewish  population  at  1,330,000  in  1913,  pp.  68-75. 
American  Jewish  Year  Book,  1919-1920,  p.  605,  estimates  the  Jewish 
population  in  New  York  iState  in  1918  as  1,603,923. 

VS.  H.  C,  30th  A.  R.,  1917-1918,  p.  405. 
Insane  and  Feebleminded  in  Institutions,   Bureau  of  Census,   1914, 
p.  27. 

'De  Fursac,  R.  and  Rosanoff,  A.,  Manual  of  Psychiatry,  1916,  p.  15. 


^2       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [194 

only  29.9  in.  Warren  County,  30.7  in  Schoharie  County, 
etc.'^  As  aforementioned,  the  Jewish  first  admissions  to  the 
civil  state  hospitals  in  1917  and  1918  averaged  about  11.6 
per  cent  of  the  total  first  admissions,  while  they  formed 
approximately  16.0  per  cent  of  the  general  population  of 
the  state,  indicating  a  rather  low  rate  of  first  admissions  to 
institutions  for  the  insane. 

(c)  Jewish  Insane  in  Neiv  York  City.  Another  definite 
and  perhaps  somewhat  more  exact  way  to  arrive  at  the  ratio 
of  the  occurrence  of  insanity  among  Jews  to  their  pro- 
portion in  the  general  population  is  to  consider  the  admis- 
sions to  the  psychopathic  wards  of  Bellevue  Hospital,  New 
York  City,  for  there  the  population  is  practically  all  urban, 
the  admissions  are  all  from  the  city  proper  (nearly  alto- 
gether from  the  Boroughs  of  Manhattan  and  the  Bronx), 
and  the  Jewish  population  is  centered  in  the  city. 

The  number  of  admissions  to  the  psychopathic  wards, 
male  and  female,  of  Bellevue  Hospital  from  September  i, 
1917  to  August  31,  1918,  totalled  6,878,  of  which  1,127  ^ 
16.38  per  cent  were  Jews.  For  the  following  year,  be- 
ginning September  i,  1918  and  ending  August  31,  19 19, 
the  total  number  of  admissions  to  the  psychopathic  wards 
of  Bellevue  Hospital  was  8,255,  of  which  1,133  or  13.72 
per  cent  were  Jews.  During  the  second  year,  as  has  been 
noted,  the  total  number  of  admissions  was  considerably 
larger  than  the  year  previous.  This  can  be  accounted  for 
by  stating  that  directly  after  the  signing  of  the  armistice 
on  November  11,  1918,  the  number  of  cases  of  alcoholism 
and  alchoholic  psychoses  admitted  to  the  psychopathic  wards 
increased  considerably;  also,  during  this  year  a  number  of 
soldiers  who  had  become  insane  while  in  service  in  various 
camps  in  the  United  States  were  sent  to  Bellevue  Hospital, 

'  S.  H.  C,  30th  A.  R.,  1917-1918,  p.  438. 


IC>5]  INSANITY  AS  A  COMMUNITY  PROBLEM  53 

psychopathic  division,  and  later  transferred  to  their  re- 
latives in  the  city.  The  incidence  of  alcoholism  and  al- 
coholic psychoses  among  Jews,  as  will  be  pointed  out  later, 
has  been  considerably  less  than  in  almost  any  other  element 
of  the  general  population  of  New  York,  and  for  this  reason, 
using  the  Bellevue  Hospital  fig-ures,  the  percentage  of  in- 
sanity among  Jews  was  13.72  per  cent  for  1918-1919; 
whereas  it  had  reached  16.38  per  cent  the  year  previous. 
The  total  population  of  New  York  City  in  191 7  was  ap- 
proximately 5,800,000;^  the  total  Jewish  population  about 
1,500,000,  or  25.8  per  cent  of  the  general  population,  with 
admission  rates  to  the  psychopathic  wards  of  Bellevue  His- 
pital  of  16.38  per  cent  one  year  and  13.72  per  cent  the 
following  year. 

To  Bellevue  Hospital  are  brought  the  insane  or  alleged 
insane  from  the  Boroughs  of  Manhattan  and  the  Bronx 
only.  Kings  County  Hospital  in  Brooklyn  receives  such 
patients  from  the  Boroughs  of  Kings  and  Queens;  Rich- 
mond Borough,  with  a  Jewish  population  of  only  5,000, 
sends  its  insane  directly  to  Manhattan  State  Hospital  after 
examination  by  two  local  physicians.  A  consideration  of 
the  total  admissions  to  the  psychopathic  wards  of  both 
Bellevue  and  Kings  County  Hospitals  for  two  years,  thus 
including  practically  the  entire  city,  will  give  a  still  better 
and  more  accurate  index  of  the  occurrence  of  insanity 
among  the  Jews  of  New  York.  The  total  number  of  ad- 
missions to  Kings  County  Hospital,  psychopathic  wards, 
from  September  i,  191 7  to  August  31,  19 18  was  2,326,  of 
which  392  or  16.85  P^^  cent  were  Jews.  For  the  following 
year,  September  i,  19 18  to  August  31,  19 19  the  total  ad- 
missions were  2,550,  of  which  429  or  16.82  per  cent  were 
Jews,  there  being  in  both  years  a  markedly  lower  rate  of 

'Dept.  of  Health,  New  York  City,  estimated  the  total  population  on 
July  I,  1917,  at  5,737,492,  Weekly  Bulletin,  July  7,  1917,  p.  223. 


54      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [196 

admissions  than  the  percentage  of  the  total  population. 
For  the  entire  city  (exclusive  of  Richmond,  which  is  practi- 
cally negligible)  Table  I  indicates  the  admissions  and  per- 
centages : 

Table  i.    Total  Admissions  to  the  Psychopathic  Wards, 
New  York  City 


Year. 

Bellevue 
Hospital. 

Kings  Co. 
Hospital. 

Total  in 
City. 

Total  Jew. 
in  City. 

Per  cent 

Total. 

Jew. 

Total. 

Jew. 

Jew.  in  City 

1917-18  

1918-19  

6,878 
8,25s 

1,127 

2,326 
2.550 

392 
429 

9,204 
10,805 

1.519 
1,562 

16.50 
14.45 

In  view  of  what  has  been  said  regarding  the  unusually 
large  total  admissions  to  Bellevue  Hospital  for  the  year 
191 8- 1 91 9,  it  might  be  advisable  to  make  sufficient  allow- 
ance for  the  increase  over  the  preceding  year  by  setting  the 
total  admissions  at  about  what  they  were  in  191 7-19 18. 
In  any  event,  the  percentage  of  Jewish  admissions  for  the 
entire  city  would  not  average  over  16.5  per  cent,  which  is 
considerably  less  than  25.8  per  cent,  the  proportion  of  Jews 
in  the  general  population  of  New  York  City. 

III.    METHODS  OF  COMMITTING  PATIENTS  TO  STATE 
HOSPITALS 

(a)  Legal  Provisions  for  Commitment.  The  patients 
admitted  to  the  psychopathic  wards  of  Bellevue  Hospital 
came  from  various  sources,  usually  being  brought  there  by 
the  special  ambulance  attached  tO'  the  psychopathic  service 
of  the  hospital.  The  transference  of  the  patients  toi  the 
hospital  is  carried  out  under  authority  of  Section  87,  of 
Article  4,  Chapter  27  of  the  Consolidated  Laws  known  as 


IC)7]  INSANITY  AS  A  COMMUNITY  PROBLEM  55 

the  "  Insanity  Law  "  relative  to  the  transfer  of  alleged  in- 
sane persons  to  the  psychopathic  wards  of  Bellevue  His- 
pital,  the  law  reading  as  follows : 

It  shall  be  the  duty  of  such  trustees  of  Bellevue  and  Allied 
Hospitals  ...  to  see  that  the  proceedings  are  taken  for  the 
determination  of  the  mental  condition  of  any  such  person  in 
the  boroughs  or  counties  mentioned,  who  comes  under  their 
observation  or  is  reported  to  them  as  apparently  insane,  and, 
when  necessary,  to  see  that  proceedings  are  instituted  for  the 
commitment  of  such  person  to  an  institution  for  the  care  of 
the  insane;  provided  that  such  report  is  made  by  any  person 
with  whom  such  alleged  person  may  reside,  or  at  whose  house 
he  may  be,  or  by  the  father,  mother,  husband,  wife,  brother, 
sister,  or  child  of  any  such  person,  or  next  of  kin  available, 
or  by  any  duly  licensed  physician,  or  by  any  police  officer,  or 
by  the  representative  of  any  incorporated  society  doing  charit- 
able or  philanthropic  work.  When  the  trustees  of  Bellevue 
and  Allied  Hospitals  are  thus  informed  of  an  apparently  in- 
sane person,  residing  in  the  boroughs  of  Manhattan  or  the 
Bronx  ...  it  shall  be  the  duty  of  these  authorities  ...  to 
send  a  nurse  or  a  medical  examiner  in  lunacy  attached  to  the 
psychopathic  ward  of  their  institution,  or  both,  to  the  place 
where  the  alleged  insane  person  resides  or  is  to  be  found.  If, 
in  the  judgment  of  the  chief  resident  alienist  of  the  psycho- 
pathic ward  or  of  the  medical  examiner  thus  sent,  the  person 
is  in  immediate  need  of  care  and  treatment  or  observation  for 
the  purpose  of  ascertaining  his  mental  condition,  he  shall  be 
removed  to  the  psychopathic  ward  for  a  period  not  to  exceed 
ten  days,  and  the  person  or  persons  most  nearly  related  to 
him,  so  far  as  the  same  can  be  readily  ascertained  by  such 
trustees  ,  .  .  shall  be  notified  of  such  removal. 

This  section  of  the  law  went  into  effect  March  5,  19 12, 
when  the  old  law  was  amended.  Prior  to  the  amendment, 
patients  were  brought  to  the  psychopathic  wards  by  the 
police  as  prisoners,  or  committed  for  examination  by  city 


56       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [igg 

magistrates.  Such  procedure  greatly  aggravated  the  mental 
infirmities,  which  require  more  tender,  skillful  and  gentle 
handling  than  medical  and  surgical  cases.  Since  this 
measure  has  became  operative  and  experienced  nurses  and 
a  special  ambulance  are  sent  for  the  patients,  thus  eliminat- 
ing the  police  as  arresting  agents  and  the  court  procedures, 
the  number  of  excited  and  disturbed  patients  received  in 
the  psychopathic  wards  has  greatly  decreased,  and  straps, 
handcuffs,  and  police  patrol  wagons  have  been  altogether 
done  away  with.^ 

The  legal  right  of  the  hospital  authorities  to  go  into  a 
home  and  forcibly  remove  a  patient  against  his  own  will 
was  questioned  for  a  time  by  those  interested  in  the  matter 
of  personal  rights.  The  opinion  of  the  Corporation  Counsel 
of  the  City  of  New  York  regarding  the  interpretation  of 
this  section  is  appended.^ 

The  obvious  purpose  of  Section  87  is  to  sanction  and  permit 
the  summary  removal  to  the  hospitals  of  alleged  insane  persons 
who,  by  their  actions,  evince  symptoms  of  insanity,  or  whose 
conduct,  in  the  judgment  of  the  medical  examiner  sent  pur- 
suant to  its  provisions,  is  such  that  it  would  be  dangerous 
to  themselves  or  to  the  community  to  allow  them  to  remain 
unrestrained  or  would  disturb  the  public  peace,  and  to  afford 
alleged  insane  persons,  in  whose  cases  these  elements  of  danger 
or  disorder  are  lacking,  opportunity  to  be  heard  before  de- 
priving them  of  their  liberty. 

In  this  view  I  am  of  the  opinion  and  advise  that  it  is  not 
contemplated  or  required  by  Section  87  that  a  person  alleged 
to  be  insane  should  be  forcibly  brought  to  the  hospital,  unless 
such  person  has  acted  in  a  disorderly  manner,  has  committed 
an  overt  act,  or  is  apparently  an  immediate  source  of  danger 
to  himself   or  to   the   community,   and   that   in   other   cases, 

'  Bellevue  and  Allied  Hospitals,  New  York  City,  A.  R.,  1912,  pp.  68-69. 
'Ibid.,  A.  R.,  1913,  p.  64. 


igg]  INSANITY  AS  A  COMMUNITY  PROBLEM  57 

recourse  should  be  had  to  that  provision  of  Section  87  which 
reads : 

"  Whenever  in  the  City  of  New  York  an  information  is 
laid  before  a  magistrate  that  a  person  is  apparently  insane, 
the  magistrate  must  issue  a  warrant  directed  to  the  sheriff  of 
the  county  in  which  the  information  is  made,  or  any  marshal 
or  policeman  in  the  City  of  New  York,  reciting  the  substance 
of  the  information  and  commanding  the  officer  forthwith  to 
arrest  the  person  alleged  to  be  insane  and  bring  him  before 
the  magistrate  issuing  the  warrant." 

It  should  be  remembered  that  the  procedure  of  summarily 
removing  a  person  to  the  hospital  against  his  will  for 
examination  as  to  his  mental  condition  would  seem  to  de- 
prive the  person  of  his  liberty  without  due  process  O'f  law, 
in  violation  of  the  fundamental  law  of  the  land.  However, 
this  section  of  the  statute  authorizes  this  procedure  as  a 
police  measure,  so  that  whenever  there  is  no  element  of 
danger  to  the  individual  himself  or  any  danger  or  distur- 
bance to  the  community,  it  would  not  be  within  the  purport 
of  the  law  to  bring  a  patient  to  the  hospital  in  this  summary- 
manner.  This  is  particularly  applicable  to  the  paranoid 
types  of  mental  disease,  which  will  be  discussed  in  another 
part  of  this  chapter. 

(b)  Social  Workers  and  Commitment  of  Patients.  In 
applying  the  various  provisions  of  the  law,  if  any  difference 
of  opinion  exists  in  the  family  regarding  the  mental  con- 
dition of  the  patient  or  his  transfer  tO'  the  hospital  for  ex- 
amination, extreme  caution  must  of  necessity  be  exercised 
in  removing  him  from  his  residence.  When  the  ''  request" 
comes  from  a  physician  or  a  "  representative  of  an  incor- 
porated society  doing  charitable  or  philanthropic  work," 
without  the  consent  of  the  family  or  relatives  of  the  patient, 
it  is  usually  inadvisable  and  frequently  fraught  with  harm 
to  remove  him  summarily  from  his  home. 


58      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [200 

The  ease  with  which  patients  may  be  brought  to  the 
hospital  might  become  too  great  a  temptation  to  social 
workers  and  representatives  oi  charitable  organizations  to 
hasten  patients  to  the  hospital  for  examination.  While  in 
a  number  of  instances  such  a  method  is  most  desirable  and 
beneficial,  many  neurotic  and  borderline  patients  might  be- 
come greatly  upset  from  the  shock  incident  to  such  trans- 
fer. Every  effort  should  always  be  made  to  bring  the 
milder  cases  of  mental  trouble  to  the  hospital  as  voluntary 
patients,  or  to  take  them  to  mental  hygiene  clinics  in  order 
to  ascertain  their  mental  condition  and  the  advisability  of 
transferring  them  to  the  hospital  for  further  examination. 
The  intent  of  this  section  of  the  law,  empowering  repre- 
sentatives of  charitable  or  philanthropic  agencies  to  apply 
for  the  mental  examination  of  persons  in  the  psychopathic 
wards,  is  altogether  a  praiseworthy  one.  However,  unless 
organizations  specializing  in  the  care  of  the  mentally  sick 
are  specifically  called  upon,  there  is,  as  pointed  out  above, 
too  much  left  to  the  judgment  of  workers  nearly  always 
without  training  in  the  observation,  care,  and  understand- 
ing of  mental  cases.  Several  training  schools  for  social 
workers  have  realized  this  fact  and  are  instituting  both 
theoretical  and  practical  courses  for  the  training  of 
psychiatric  social  workers. 

(c)  The  Police  and  Mental  Cases.  As  a  result  of  much 
experience  it  has  been  found  advisable  to  have  a  police 
officer  present  at  the  house  of  the  patient  when  the  ambul- 
ance arrives,  especially  if  the  patient  is  unduly  excited  and 
liable  to  do  harm  to  himself  or  to  others  if  he  should  see  the 
ambulance  and  nurses.  The  presence  of  a  police  officer  is 
also  at  times  necessary  when  the  patient  has  no  friends  or 
relatives  residing  with  him;  in  such  instances  the  duty  of 
the  officer  is  to  take  care  of  the  personal  effects  and  pro- 
perty of  the  patient  after  his  removal  to  the  hospital. 


^Ol]  INSANITY  AS  A  COMMUNITY  PROBLEM  ^q 

On  May  5,  191 9,  an  amendment  to  the  insanity  law  pro- 
vided that  in  the  City  of  New  York  the  officer  commanded 
by  a  warrant  to  arrest  a  person  alleged  to  be  insane  must 
bring  him  before  the  magistrate's  court  out  of  which  the 
warrant  was  issued,  instead  of  before  the  magistrate  issu- 
ing the  warrant.  Though  the  number  of  insane  or  alleged 
insane  persons  thus  brought  to  court  is  small  in  comparison 
with  the  total  number  committed,  still,  with  the  system  of 
rotating  magistrates  as  it  exists  in  New  York  City,  the 
apparent  difficulty  and  inadvisability  of  taking  aii  insane 
person  to  another  section  of  the  city  than  the  one  in  which 
he  lives,  is  quite  obvious/ 

One  of  the  difficulties  experienced  by  friends  and  rela- 
tives as  well  as  by  mental  hygiene  workers  of  private  organ- 
izations is  in  having  certain  patients  brought  to  the  hospital 
without  court  proceedings.  The  police  department,  acting 
for  the  Ambulance  Board  of  the  city,  must  be  notified  when 
an  ambulance  is  wanted.  As  a  rule  a  policeman  is  either 
asked  to  telephone  for  the  ambulance  or  he  is  at  the  house 
when  the  ambulance  calls.  The  patient,  especially  if  a 
paranoiac,  will  speak  lucidly  and  intelligently  and  the  officer 
frequently  accuses  the  relatives  of  the  patient  of  attempting 
to  "  railroad  "  the  patient  to  an  insane  asylum.  The  same 
also  happens  when  a  hospital  interne  responds  to  an  am- 
bulance call,  and,  not  having  sufficient  experience  in  the 
diagnosis  of  mental  diseases,  refuses  to  accept  the  patient 
for  transfer  to  the  hospital.  In  a  number  of  cases  it  is  for 
these  reasons  a  matter  of  weeks  before  a  person  whose 
relatives  realize  that  a  condition  of  mental  abnormality  ex- 
ists, is  at  last  brought  to  the  hospital.  Once  there,  the 
Commitment  Law  of  the  state,  probably  the  most  practic- 
able in  the  country,  preserves  the  constitutional  rights  of 
the  individual.     It  involves  little  publicity,  is  not  cumber- 

*  Laws  of  1919.  sec.  87,  chap.  380. 


6o      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [202 

some,  and  is  well  safeguarded.^  In  other  cities  in  the  state 
the  provisions  for  the  care  of  the  insane  pending  commit- 
ment have  shown  many  shortcomings,  as  such  persons  have 
been  detained  in  jails  and  almshouses.  In  order  to  correct 
this  evil  a  law  was  passed  in  1914  authorizing  the  State 
Hospital  Commission  to  enforce  its  requirements  as  to 
suitable  care  for  the  dependent  insane  during  the  time  steps 
are  being  completed  for  their  commitment  to  a  state  hospital.^ 
This  has  helped  reduce  the  number  of  instances  where  im- 
proper care  is  bestowed  and  within  a  short  time  adequate 
provision  for  proper  care  should  be  found  in  every  county 
in  the  state.® 

There  are  two  methods  in  which  studies  of  the  nature  of 
this  work  may  be  made:  (i)  the  statistical  method;  (2) 
the  case  method.  It  is  the  purpose  to  follow  both  these 
methods  in  this  study,  and  it  may  be  well  to  define  the 
various  terms  to  be  used,  as  well  as  to  present  the  classifica- 
tion and  give  a  brief  definition  and  review  of  the  different 
psychoses  and  neuroses  to  be  considered. 

IV.    DEFINITION  OF  TERM  ""  INSANITY  "'' 

However,  before  proceeding  to  the  task  of  setting  forth 
the  definitions  spoken  of,  the  question  of  the  meaning  or 
connotation  of  the  concept  insanity  should  be  settled  if  pos- 
sible.* Many  attempts  have  been  made  to  formulate  de- 
finitions of  the  term,  and  several  are  herein  presented  for 
consideration.     Thus,  White  ^  states  that  insanity  is  not  a 

*  State  Comm.  in  Lunacy,  A.  R.,  1890,  p.  125. 

*Laws  of  1914,  chap.  305.  (Incorporated  in  the  Insanity  Law  as 
sec.  20.) 

»S.  H.  C,  26th  A.  R.,  1913-1914,  p.  277. 

*For  a  full  discussion  of  the  term  see  article  by  William  A.  White 
on  "  Underlying  Concepts  in  Mental  Hygiene,"  in  Mental  Hygiene, 
Jan.,  1917,  pp.  7-8. 

5  White,  William  A.,  Outlines  of  Psychiatry,  1918,  p.  17. 


203]  INSANITY  AS  A  COMMUNITY  PROBLEM  6i 

disease;  it  is  rather  a  symbol  grouping  for  a  large  number 
of  different  mental  diseases  which  tend  to  arrange  them- 
selves with  greater  or  less  distinctness  into^  circumscribed 
groups  of  reaction  trends.  According  to  Dercum  ^  insanity 
may  be  defined  as  a  diseased  state  in  which  there  is  more 
or  less  persistent  departure  from  the  normal  manner  of 
thinking,  acting,  and  feeling.  Still  another,  though  kind- 
red interpretation  of  the  term  is  offered  by  Craig "  in  stat- 
ing that  a  person  may  be  considered  of  unusual  mind  if 
from  some  mental  cause :  ( i )  he  is  unable  tO'  look  after 
himself  and  his  affairs;  (2)  he  is  dangerous  to  himself  or 
tO'  others;  (3)  he  interferes  with  society,  i.  c,  is  unable  to 
adjust  himself  to  his  surroundings.*  Maudsley  *  wrote  that 
the  most  prominent  pathological  characteristic  of  the  in- 
sane is  a  complete  or  almost  complete  absence  of  moral  feel- 
ing and  moral  ideas.  A  more  concise  definition  is  that  of- 
fered by  Peterson  when  he  states  that  "  insanity  is  a  mani- 
festation in  language  or  conduct  of  disease  or  defect  of  the 
brain."  ^  As  a  scientific  term,  insanity  is  falling  into  disuse 
and  now  retains  a  significance  imiainly  in  a  legal  sense;  like 
lunacy  it  seems  destined  to  become  obsolete.*^  It  would  be 
best  to  restrict  the  applicatioii  o'f  the  term  to  cases  in  which 
the  mental  disorder  is  of  such  a  nature  as  to  render  advisable 
commitment  for  treatment  or  custody  to  a  special  institution, 
or  care  under  trained  and  expert  supervision.^ 

1  Dercum,  Francis  X.,  A  Clinical  Manual  of  Mental  Disease,  1914,  p.  21. 

2  Craig,  Maurice,  Psychological  Medicine,  1905,  p.  20, 

•Mercier,  Charles  A.,  Textbook  of  Insanity  and  other  Mental  Diseases, 
1914,  p.  42. 

*  Maudsley,  Henry,  Responsibility  in  Mental  Disease,  1874,  PP-  171-172. 

*  Church,  A.  and  Peterson  F.,  Nervous  and  Mental  Diseases,   1901, 
p.  630. 

•De  Fursac  and  Rosanoff,  op,,  cit.,  Introduction,  p.  xi. 

^Peterson,  Frederick,  Mental  Diseases,  1899,  P-  603,  quotes  the  noted 


62       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [204 
.     V.    CAUSES  OF  INSANITY 

There  has  been  much  speculation  as  to  the  causes  of 
insanity,  though  some  factors  have  been  definitely  deter- 
mined upon  as  being  responsible  for  a  large  proportion  of 
the  cases  of  mental  alienation  that  fill  our  state  hospitals  and 
cost  the  various  communities  and  states  in  the  country  large 
sums  for  their  care  and  treatment/     Broadly  speaking  and 
with  special  reference  to  causation  the  mental  disorders  may 
be  divided  into  two  groups :  ( i )  Exogenous,  or  where  the 
causes  are  chiefly  external;    (2)    Endogenous,   where  the 
existence  of  external  causes  or  of  primary  tissue  changes  in. 
the  brain  has  not  been  demonstrated.     The  causes  found  in 
this  group  are  internal,  the  insanity  growing,  as  it  were  out 
of  the  personality."     Among  causes  affecting  the  first  class^ 
are  syphilitic  infection,  poisons  introduced  into  the  body, 
(as  alcohol,   cocaine,   opium  and   its  derivatives,   etc.)    or 
created  within  the  body,  and  exhaustion.     Heredity  plays 
a  most  important  part  in  the  causation  of  mental  disease  in 
the  endogenous  group.     Kraepelin  classifies  the  causes  in 
this  class  under  the  divisions  of  general  predisposition  and 
personal  predisposition.^     Modern  physiological  psychology 

English  jurist,  Lord  Justice  Blackburn,  who  once  said  while  giving 
evidence  before  a  committee  of  the  House  of  Commons,  "  I  have  read 
every  definition  which  I  could  meet  with,  and  never  was  satisfied  with 
one  of  them,  and  have  endeavored  in  vain  to  make  one  satisfactory  ta 
myself.  I  verily  believe  it  is  not  in  human  power  to  do  so."  Clouston, 
T.  S.,  Unsoundness  of  Mind,  191 1,  p.  i,  also  emphasizes  the  difficulty 
encountered  when  attempting  to  give  a  satisfactory  definition  of  the  term. 

^  Number  of  patients  on  books  in  New  York  State  Hospitals  at  close 
of  fiscal  year  June  30,  1918 :  in  civil  hospitals  37.352 ;  in  hospitals  for 
the  criminal  insane  1,420.  (S.  H.  C,  30th  A.  R.,  1917-1918,  p.  9.)  Total 
expenditures  for  the  year  approximately  $11,000,000.    Ibid.,  p.  25. 

*Hoch,  August,  "The  Manageable  Causes  of  Insanity,"  Nezv  York 
State  Hospitals  Bulletin,  Sept.,  1909,  pp.  1-3.  See  also  Thomson,  J. 
Arthur,  Heredity,  1908,  pp.  263-264,  for  a  discussion  of  this  classi- 
fication from  a  somewhat  different  viewpoint. 

» Kraepelin,  Emil,  Psychiatrie,  Achte  Auflage,  i  Band,  pp.  140-208. 


205]  INSANITY  AS  A  COMMUNITY  PROBLEM  63 

emphasizes  the  fact  that  there  are  innumerable  phenomena 
which  indicate  that  the  mind  operates  as  a  true  cause  within 
the  structure  of  the  body,  and  that  the  reverse  relation  is 
also  true/  Considering  another  method  of  classification, 
it  may  be  stated  that  the  essential  causes  of  insanity  are  = 
heredity,  alcoholism,  syphilis,  and  head  injuries;  and  that 
there  are  numerous  and  complex  incidental  or  contributing 
causes,  which  in  themselves  do  not  suffice  to  produce  in- 
sanity, but  do  so  only  in  the  presence  of  an  essential  cause. 
Alcohol  and  head  injuries  belong  to  this  class  also,  as  do 
various  psychic  conditions,  common  among  which  are 
business  and  domestic  troubles,  love  affairs,  death  or  illness 
of  relatives.  Other  etiological  factors  that  may  be  men- 
tioned are  race,  age,  sex,  environment,  occupation,  marital 
condition,  education,  and  immigration. - 

(a)  Heredity.  In  any  discussion  of  insanity  the  ques- 
tion of  heredity  looms  up  as  probably  the  most  important 
factor.^  An  inherited  predisposition  to  mental  disorder  is 
found  in  from  30  to  90  per  cent  oi  cases  according  tO'  dif- 
ferent authorities.'*  This  wide  variation  in  percentages 
is  due  to  the  inability  to  gather  such  statistics  accurately, 
the  lack  of  cooperation  of  relatives  in  obtaining  the  neces- 
sary information,  and  the  failure  to  consider  large  enough 
groups  in  such  studies  to  render  them  of  any  statistical 

^Ladd,  G.  W.  and  Woodworth,  R.  S.,  Elements  of  Physiological 
Psychology,    1915,   pp.  644-646. 

"  De  Fursac  and  Rosanoff,  op.  cit.,  pp.  2-20. 

'Mercier,  Charles  A.,  Crime  and  Criminals,  1918,  sets  forth  his  doc- 
trine of  the  causation  of  insanity,  stating  that  it  is  due  in  varying 
proportions  to  the  two  factors  of  heredity  and  stress — to  the  stress  of 
circumstances  acting  upon  an  innate  constitution ;  to  varying  propor- 
tions of  heredity  and  environment,  p.  225.  Mercier,  iCharles  A.,  Text- 
book of  Insanity  and  other  Mental  Diseases,  1914,  pp.  3-4.  For  opinions 
similar  to  the  above  see  13th  A.  iR.,  S.  Comm.  in  Lun.,  1900-1901,  p.  37. 

*  White,  William  A.,  Outlines  of  Psychiatry,  1918,  p.  20. 


64      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [206 

value/  In  one  careful  study  of  a  comparatively  large  num- 
ber of  cases,  an  investigation  by  Rosanoff  and  Orr,  the  cor- 
respondence between  the  actual  findings  and  the  theoretical 
expectation  acording  to  the  ^Nlendelian  theory,  was  very 
close.-  However,  it  is  quite  apparent  that  the  scientific 
study  of  heredity  cannot  be  applied  to  the  diseases  of  man 
with  as  much  accuracy  as  in  the  vegetable  kingdom  or 
among  the  lower  animals.  The  human  race  is  not  open  to 
Mendel's  essential  methods,  and  its  mere  complexity  in- 
volves innumerable  differences  from  lower  forms  of  life.^ 
Among  other  things,  there  is  general  agreement  that  the 
appearance  or  non-appearance  of  a  characteristic  may  be  in 
part  decided  by  environmental  influences.*  Given  the  op- 
portunity, certain  characters  may  manifest  themselves  which 
without  such  opportunity  must  have  lain  dormant.' 

Our  present-day  knowledge  of  heredity  as  applied  to  man 
is  as  yet  insufficient  to  permit  us  to  take  a  definite  stand  as 
to  the  inheritance  of   psychoses.*'      Furthermore,   there   is 

^Church  and  Peterson,  Mental  Diseases,  p.  637,  quote  Lunacy  Com- 
mission tables  showing  that  of  136.478  admissions  to  asylums  in 
England  and  Wales,  heredity  influence  ascertained  in  only  20.5  per 
cent  of  admissions. 

"Rosanoff,  A.  J.  and  Orr,  Florence  I.,  "A  Study  of  Heredity  in 
Insanity  in  the  Light  of  the  Mendelian  Theory."  Bulletin  No.  5, 
Eugenics  Record  Oifice,  Cold  Spring  Harbor,  N.  Y. 

'  Cowers,  Wm.  R.,  "  Heredity  and  Disease,"  Royal  Society  of 
Medicine,  1909,  vol.  ii,  p.  15. 

*Lugaro,  Ernesto,  Modern  Problems  in  Psychiatry,  1909  (trans,  by 
D.  Orr  and  R.  G.  Rows)  emphasizes  the  fact  that  it  is  not  a  rare 
occurrence  to  see  robust  individuals  spring  from  a  marriage  of  weak 
individ-uals  when  the  conditions  of  life  are  favorable,    p.  212. 

*Bateson,  W.,  Mendel's  Principles  of  Heredity,  1909,  pp.  303-305- 

•Davenport,  Charles  B.,  Heredity  in  Relation  to  Eugenics,  1911, 
points  out  in  preface  to  book  (p.  in)  that  a  large  amount  of  in- 
vestigation will  be  required  before  it  will  be  possible  to  take  a  definite 
stand,  and  that  the  advance  thus  far  made  is  chiefly  in  getting  a  better 
method  of  study. 


207]  INSANITY  AS  A  COMMUNITY  PROBLEM  65 

Still  too  much  speculation  in  the  field  of  psychiatry  as  to  the 
origin  and  course  of  certain  psychoses  to  make  it  advisable 
to  accept  as  final  any  of  a  number  of  theories  that  have  been 
formulated  to  date.  There  is  even  the  feeling  among 
psychiatrists  and  students  of  heredity  that  the  psychoses 
may  represent  disease  processes  rather  than  true  heredity,^ 
or  that  they  represent  abnormal  variations  unfitted  for  sur- 
vival in  the  world  as  it  is  at  present  organized.  Thomson, 
in  his  well-known  volume  on  *'  Heredity,"  states 

It  should  be  recognized  that  man  has  created  around  himself 
a  social  heritage  which  often  evolves  quickly,  hurrying  and 
pressing  its  creator,  who  cannot  always  keep  pace  with  it.  This 
is  the  frequent  condition  of  mental  disorder.  The  attempt  to 
keep  pace  with  the  changes  in  environment — physical,  biologi- 
cal, psychical  and  social,  causes  a  strain  that  provokes  disease." 

What  is  needed  in  order  to  determine  tne  actual  bearing  of 
heredity  on  insanity  is  the  establishment  of  an  organized  re- 
search which  would  especially  make  a  study  of  the  descen- 
dents,  normal  and  otherwise,  of  the  insane  confined  in  his- 
pitals.  From  the  studies  already  made  we  know  that  in- 
sane patients  have  had  a  poor  heredity  in  a  greater  per- 
centage of  cases  than  has  been  the  case  among  normal  per- 
sons. The  researches  suggested  must  necessarily  extend 
over  a  period  of  years  and  until  they  are  inaugurated  and 
completed,  the  more  accurate  knowledge  of  the  relationship 
existing  between  heredity  and  insanity  will  remain  at  least 
partly  unknown.^ 

'  Myerson,  Abraham,  "Mental  Disease  in  Families,"  Mental  Hygiene, 
April,  1919,  p.  239. 

'  Thomson,  J.  Arthur,  Heredity,  1908,  p.  253. 

*  During  the  year  ending  Sept.  30,  1910,  in  the  New  York  State 
Hospitals,  in  the  cases  where  positive  information  could  be  elicited, 
there  was  a  reported  history  of  insanity  in  27  per  cent  of  the  male,  and 
32  per  cent  of  the  female  patients.  (White  and  Jeliffe,  Modern  Treat- 
ment of  Mental  Disorders,  vol.  i,  p.  812.) 


66      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [208 

(b)  Alcohol.  Another  essential  cause  of  insanity  is  the 
excessive  indulgence  in  alcohol,  which  produces  the  familiar 
picture  of  drunkenness,  and  such  excesses  if  frequently  re- 
peated, are  apt  sooner  or  later  to  produce  one  or  another  of 
the  alcoholic  psychoses.^  Chronic  alcoholic  addicts  are 
often  of  a  psychopathic  constitution,  congenital  or  ac- 
quired,- and  are  characterized  by  a  gradually  progressive 
dementia,  with  diminished  capacity  for  work,  faulty  judg- 
ment, defective  memory,  moral  deterioration,  occasional  de- 
lusions, and  various  nervous  symptoimis.^ 

In  a  study  relating  to  the  use  and  effect  of  alcohol  in  rela- 
tion to  the  alcoholic  ps3xhoses,  it  was  found  that,  ( i )  the 
drink  habit  leading  to  alcoholic  insanity  is  usually  formed 
in  early  life,  males  acquiring  the  habit  earlier  than  females; 
(2)  the  average  duration  of  the  alcoholic  habit  prior  to 
admission  to  the  hospital  for  the  insane  is  approximately 
22  years  among  the  males  and  16  years  among  the 
females;  (3)  the  liquors  causing  alcoholic  insanity  in  New 
York  State  are  principally  whiskey  and  beer,  the  former 
appearing  to  be  the  principal  factor  in  the  majority  of  cases ; 
(4)  either  regular  or  periodic  drinking  may  lead  to  alcoholic 
insanity,  more  than  three-fourths  of  the  patients  observed 
(464)  having  been  regular  drinkers  prior  to  admission;  (5) 
a  fixed  habit  of  excessive  drinking  with  frequent  intoxica- 

*  Kraepelin  pointed  out  that  10  per  cent  of  the  patients  in  the  asylums 
for  the  insane  in  the  German  Empire  were  committed  on  account  of 
mental  diseases  due  to  alcohol.  In  some  institutions  the  number  was 
as  high  as  30  per  cent,  and  even  then  these  figures  did  not  include 
numerous  cases  where  alcohol  was  the  exciting  cause  of  the  trouble, 
as  in  cases  of  mania,  epilepsy  and  paresis.  (Kraepelin,  "Duty  of  the 
State  in  the  Care  of  the  Insane,"  trans,  by  Stewart  Paton,  Amer.  la. 
of  Ins.,  1900,  p.  236.) 

'Jacoby,  Geo.  W.,  Unsound  Mind,  1918,  p.  288. 

^Diefendorf,  A.  Ross,  Clinical  Psychiatry,  1907,  p.  288. 


i 


209] 


INSANITY  AS  A  COMMUNITY  PROBLEM 


67 


tion  precedes  the  mental  breakdown  in  a  great  majority  of 
the  cases. ^ 

The  spread  of  the  prohibition  movement  throughout  the 
country  during  the  past  decade  has  resulted,  to  some  ex- 
tent at  least,  in  the  decrease  in  the  number  of  cases  of 
alcoholic  insanity  admitted  to  the  New  York  State  Hos- 
pitals. The  following  figures  indicate  the  gradual  decrease 
in  the  percentage  of  cases  of  alcoholic  insanity  annually 
adimitted  from  1909  tO'  1916,"  and  now  that  the  prohibition 
amendment  to  the  Constitution  has  become  law,  a  more 
substantial  decrease  may  naturally  be  expected  to  follow. 
From  October  i,  1908  to  June  30,  1916,  58,011  patients 
were  admitted  to  New  York  State  hospitals. 

Table  2.    Number  of  Cases  of  Alcoholic  Insanity 


All  Admissions. 

Per  cent 

of  Total 

Year. 

Number. 

Admissions. 

Male, 

Female. 

Male. 

Female. 

526 
546 
530 
529 
535 
418 

321 

255 

145 
148 

173 

153 
155 
137 
III 
98 

15.2 

14.7 
14.1 
14.0 
13.5 

lO.I 

7.8 
8.0 

4.6 
4.4 
5.0 

4-4 
4.2 

3-6 
2.9 

3-2 

IQI-J 

1916  (9  months). 

In  the  year  191 7  there  was  an  increase  in  the  number  of 
first  admissions  in  alcoholic  insanity,  a  total  of  549,  437 
males  and  157  females,  or  8.6  per  cent  of  the  total  first  ad- 

^  Pollock,  Horatio  M.,  State  Hospitals  Bulletin,  Aug.,  1915. 
'Pollock,  Horatio  M.,  "Decline  of  Alcohol  as  a  Cause  of  Insanity," 
Psychiatric  Btdletin,  vol.  xi,  Apr.,  1917,  no.  2,  pp.  103-104. 


b 


^      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [210 

missions  being  classified  in  this  group.  The  reasons  for 
the  marked  change  in  this  particular  year  are  not  known. ^ 
For  the  year  ending  June  30,  19 18,  the  percentage  of 
alcoholic  cases  admitted  was  7.3  per  cent  males,  and  3.0 
per  cent  females,  the  lowest  rate  since  1909.^  A  more 
marked  decrease  is  expected  to  follow  within  the  next  few 
years. 

(c)  Syphilis.  Syphilis  appears  as  the  essential  cause 
of  all  cases  of  general  paralysis  and  of  cerebral  syphilis,  as 
well  as  of  a  large  proportion  of  the  cases  of  cerebral 
arteriosclerosis.^  General  paralysis  hardly  ever  develops 
before  from  ten  to  twenty  years  after  the  primary  syphilitic 
infection.^  Not  counting  cases  of  arteriosclerosis,  which 
are  not  always  of  syphilic  origin,  19.4  per  cent  of  all  male 
first  admissions  and  7.0  per  cent  of  all  female  first  ad- 
missions to  the  New  York  State  hospitals  during  a  given 
year,  occurred  on  the  basis  of  syphilis  as  an  essential 
cause. ^  For  the  year  ending  June  30.  1918,  the  cases  of 
general  paralysis  which  have  been  gradually  increasing  in  re- 
cent years,  showed  a  percentage  of  13.4  of  all  first  admis- 
sions.^ It  is  now  a  recognized  fact  that  without  a  previous 
syphilis  there  can  be  no  paresis.'^  Syphilis  is  not  a  sole 
factor,  however.  Only  a  very  small  proportion  of  the 
persons  who  are  syphilitic  develop  general  paralysis,  and 
•in  many,  if  not  almost  all  cases  of  general  paralysis  it  has 
been  found  that  the  patient  has  recently  passed  through  a 

^S.  H.  C,  29th  A.  R.,  1916-1917,  p.  407- 
2  S.  H.  C,  30th  A.  R.,  p.  285. 
*De  Fursac  and  Rosanoff,  op.  cit.,  pp.  9-10. 

*Kraepelin,  Clinical  Psychiatry  (trans,  by  Thomas  Johnstone),  1917, 
p.  41- 
»S.  H.  C,  25th  A.  R.,  p.  312. 
"S.  H.  C,  30th  A.  R.,  p.  284. 
'Dercum,  Clinical  Manual,  p.  256. 


21 1  ]  INSANITY  AS  A  COMMUNITY  PROBLEM  69 

period  of  mental  or  other  stress,  which  has  seemed  to  de- 
termine the  onset  of  the  disease/ 

(d)  Injuries  and  Other  Causes.  Head  injuries  are  re- 
sponsible for  but  a  small  percentage  of  the  cases  admitted 
to  the  state  hospitals.  In  1918  there  were  only  15  cases 
thus  admitted,  13  being  men  and  2  women.  In  191 7  there 
were  but  18  cases."  These  cases  are  far  more  often  brought 
to  general  hospitals  than  to  hospitals  for  the  insane  for 
reasons  that  are  sufficiently  obvious. 

(e)  Contributing  Causes.  'As  mentioned  above  there 
are  a  number  of  contributing  causes  of  insanity  which  in 
themselves  are  not  responsible  for  any  large  percentage  of 
cases  of  insanity,  but  which  have,  however,  become  re- 
cognized as  important  contributing  factors  in  the  causa- 
tion of  insanity.  A  number  of  these  factors  have  already 
been  mientioned,  and  to  them  may  be  added  bodily  diseases ;  ^ 
overwork,  rarely  a  cause  in  healthy  persons ;  '^  and  the  group 
of  physiological  factors  including  puberty,  the  puerperal 
state,^  the  climacteric  and  seniHty,  all  of  which  are  indirect 
strains  to  which  the  organism  is  subject,  by  reason  of  the 
more  or  less  profound  physiological  commotions  they  arouse 
in  the  nervous  system.® 

VI.    CLASSIFICATION  OF  MENTAL  DISEASES 

(a)  Introduction.  There  has  been  much  difficulty  ex- 
perienced in  constructing  a  final  standard  classification  of 
mental  diseases,  due  largely  to  the  question  as  to  whether 

^  Mercier,  Textbook  of  Insanity,  p.  244. 

'  S.  H.  C,  30th  A.  R,  p.  284. 

'  Mercier,  Textbook  of  Insanity,  pp.  21-22. 

^  Craig,  Maurice,  Psychological  Medicine,  p.  29. 

5  See  Lugaro,  Modern  Problems  in  Psychiatry,  pp.  2ys-2'/6',  also 
Mercier,  Crime  and  Criminals,  1918,  p.  195  for  a  discussion  of  the 
puerperal  state  and  insanity. 

*Church  and  Peterson,  Nervous  and  Mental  Diseases,  p.  668. 


70      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [212 

such  classification  should  be  established  on  an  etiological 
basis,  on  symptomatology,  or  from  the  point  of  view  of 
pathological  anatomy/  Various  classifications  have  been 
proposed,'  but  the  one  followed  in  this  work  is  the  classifica- 
tion used  in  the  New  York  State  Hospitals  and  gradually 
being  extended  to  all  the  hospitals  for  the  insane  in  the 
United  States.^ 

Table  3  follows  the  classification  above  alluded  to  and 
sets  forth  the  psychoses,  neuroses,  and  other  ailments  of 
Jewish  admissions  to  the  psychopathic  wards  of  Bellevue 
Hospital  for  a  period  of  a  year.  In  order  that  this  study 
may  be  intelligible  to  the  layman  as  well  as  to  the  social 
worker,  a  brief  discussion  of  the  nature,  prognosis  and 
treatment  of  the  various  psychoses  will  accompany  the  con- 
sideration of  the  statistics  presented.  In  accounting  for  the 
large  number  of  males  (673)  admitted  in  comparison  to 
the  number  of  females  (454)  it  should  be  noted  that  there 
are  relatively  more  males  in  the  foreign-bom  white  popula- 
tion of  the  country  than  in  the  native-born  white  population; 
a  ratio  of  129.9  males  to  100  females  for  the  former  com- 
pared with  102.7  to  100  for  the  latter.* 

(b)  Senile  Psychosis.  The  senile  psychoses,  of  which 
there  were  16  male  and  25  female  admissions,  are  character- 
ized by  a  gradually  progressive  mental  deterioration  accom- 

^Diefendorf,  A.  Ross,  Clinical  Psychiatry,  pp.  116-117. 

•White,  Outlines  of  Psychiatry,  1918,  p.  19,  suggests  that  the  following 
be  used :  paranoia  and  paranoia  states ;  manic-depressive  psychoses ; 
paresis,  dementia  praecox,  senile  and  arteriosclerotic  psychoses,  infec- 
tion exhaustion  psychoses,  toxic  psychoses,  those  associated  with  or- 
ganic diseases  and  injury  of  the  brain,  symptomatic  psychoses,  border- 
line states,  and  idocy  and  imbecility. 

'  I'ide  Statistical  Manual  for  the  Use  of  Institutions  for  the  Insane, 
prepared  by  the  American  Medico-Psychological  Association  and  the 
National  Committee  for  Mental  Hygiene  (pamp.  40  pp.)  1918. 

*Insane  and  Feebleminded  in  Institutions,  Bureau  of  Census,  1914,  p.  27. 


213]  INSANITY  AS  A  COMMUNITY  PROBLEM 

Table  3.    Psychoses  of  Admissions 


71 


Diagnosis. 


Senile  Psychosis   

Arteriosclerosis 

Organic  Nervous  Dis 

General  Paralysis 

General  Paralysis,  Juv. . . . 

Lues 

Cerebral  Syphilis 

Chorea 

Brain  Tumor 

Cerebral  Hemorrhage  .... 

Chronic  Alcoholism 

Intoxication  Psychoses  . . . 

Toxic  Delirium   

Heroin  Poisoning 

Infection  Exhaustion 

Manic  Depressive 

Manic  Depressive  Mixed  . 

Allied  to  Man.  Dep 

Involution  Melancholia  . . 
Dementia  Praecox,  Para.  . 
Dementia  Praecox,  Kata. . 
Dementia  Praecox,  Hebe . 
Dementia  Praecox,  Simple 
Dementia  Praecox,  Allied . 

Paranoid  Conditions 

Epilepsy 

Psychoneurotic   

Hysteria 

Hysterical  Episode 

Constitutional  Infer 

Mental  Defective 

Imbecility 

Depression  Undiff 

Transitory  Confusion 

Hypomanic 

Unclassified 

Not  Insane 

Totals 


Male. 


16 

17 

12 

88 

I 

I 

3 
I 

4 
I 

17 
3 
I 
2 

4 
102 

35 

30 

I 

44 

5 

118 

21 

19 

8 

32 

4 

I 

I 

21 

26 

7 
I 

3 

7 
16 


Female. 


673 


25 
2 

6 
II 


f3 
103 

54 
32 

5 
34 

I 

34 
18 

24 

2 

14 

9 
I 

9 

15 
I 

17 
2 
I 
I 

9 


454 


Total. 


41 
19 
18 

99 
I 
I 

5 
2 

4 
I 

19 
3 
I 
8 

17 

205 

89 

62 

6 

78 
6 
152 
39 
43 
10 
46 

4 
10 

2 
30 
41 

8 
18 

5 


25 


1,127 


panied  by  a  series  of  lesions  in  the  central  nervous  system.^ 
The  most  conspicious  feature  of  these  cases  is  a  defect  of 
memory,  especially  for  more  recent  events,-  and  often  an 

•  Dief endorf,  p.  369. 

*  Mercier,  Textbook  of  Insanity,  p.  309. 


72       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [214 

outbreak  of  ill-temper.  The  course  of  the  affection  is  pro- 
gressive until  death.  The  patients  finally  become  com- 
pletely demented  so  that. they  are  wholly  disorientated,  con- 
fused, know  no  one  around  them;  in  fact  may  not  even 
know  their  own  nam^s.^  The  disease  is  encountered  most 
frequently  between  sixty  and  seventy-five  years  of  age ;  in- 
dividuals with  a  faulty  constitutional  endowment,  worn 
with  hardships,  and  especially  those  addicted  to  excesses, 
may  succumb  before  sixty. 

(c)  Arteriosclerosis.  Arteriosclerosis  was  the  diagnosis 
in  the  cases  of  17  males  and  2  females.  This  disease  is  not, 
as  some  have  thought,  always  of  syphilitic  origin  or  affec- 
tion,' but  may  also  be  brought  on  by  gout,  lead  poisoning, 
alcoholism,  pulmonary  and  cardiac  conditions.^  Among  the 
physical  symptoms  are  headaches,  insomnia,  muscular 
weakness,  attacks  of  faintness  or  dizziness,  epileptiform  or 
apoplectiform  seizures.  The  mental  symptoms  indicate  dim- 
inished capacity  for  work,  undue  fatigability,  emotional  in- 
stability and  depression;  later,  forgetfulness  and  general 
mental  deterioration.  The  course  of  the  disease  in  most 
cases  extends  over  a  number  of  years,  even  ten  or  twenty 
years.  The  prognosis  is  unfavorable  for  recovery,  though 
under  favorable  conditions,  such  as  rest,  freedom  from 
worry  or  excitement,  moderation  in  eating  and  drinking,  the 
condition  may  remain  approximately  stationary  for  months 
or  even  years.*  A  study  of  the  New  York  State  Hospital 
statistics  has  shown  that  the  senile  and  arteriosclerotic,  as 
well  as  the  paretic  groups,  have  high  rates  of  first  admis- 

'  White,  Outlines  of  Psychiatry,  p.  183. 
'  De  Fursac  and  Rosanoff,  p.  444. 
*  Church  and  Peterson,  p.  195. 
*De  Fursac  and  Rosanoff,  pp.  448,  452. 


215]  INSANITY  AS  A  COMMUNITY  PROBLEM  73 

sions  and  deaths,  with  low  rates  of  readmissions  and  dis- 
charges/ 

(d)  Organic  Nervous  Diseases.  Psychic  disorders  in- 
duced by  pathologic  processes  in  the  brain,  such  as  men- 
ingitis, tumor,  softening,  and  hemorrhage,  are  included 
under  the  category  of  organic  nervous  diseases.  Emotional 
irritability,  hallucinations  of  the  various  senses,  defects  of 
intelligence,  and  stuporous  conditions  are  common  mental 
manifestations  of  these  processes.  Eighteen  such  cases 
were  admitted,  12  males  and  6  females. 

(e)  General  Paralysis.  Some  consideration  has  already 
been  given  to  syphilis  as  a  cause  of  mental  disease,  and  from 
the  figures  in  Table  3,  it  is  seen  that  there  were  99  cases  of 
general  paralysis,  88  males,  11  females  and  one  case  of 
juvenile  general  paralysis,  all  of  which  were  a  result  of 
syphilis.-  About  9  per  cent  of  Jewish  admissions  were  dir- 
ectly traceable  to  syphilis  as  the  cause  of  the  mental  dis- 
ease; ^  this  includes  the  juvenile  case,  which  developed  years 
after  the  primary  infection.'*  Studies  of  recent  immiigra- 
tion,  that  is,  prior  to  1914,  indicate  that  three-fourths  of 

^Psychiatric  Bulletin,  vol.  ii,  no.  iv,  Oct.,  1917,  New  York  State  Hos- 
pital Statistics.  Death  rate  per  1,000  patients  under  treatment  in  prin- 
cipal groups  of  psychoses  in  civil  state  hospitals  for  1918  was  as  follows : 
general  paralysis  352.8,  cerebral  arteriosclerosis  340.2,  senile  297.2,  these 
being  three  highest  figures.     (S.  H,  C,  30th  A.  R.,  p.  312.) 

''For  a  comprehensive  and  thorough  study  of  general  paralysis,  vide 
Kraepelin,  "  General  Paresis,"  Nervous  and  Mental  Disease  Mongo- 
graphs,  series  no.  14. 

•General  paralysis  constituted  13.4  per  cent  of  all  first  admissions  to 
the  New  York  State  Hospitals  for  the  year  ending  June  30,  1918. 
(S.  H.  C,  30th  A.  R.,  p.  284.) 

*  Stokes,  John  H.,  The  Third  Great  Plague,  1917,  presents  a  satis- 
factory discussion  of  the  whole  question  of  syphilis  and  its  effects 
upon  society.  See  also  Vedder,  Edward  B.,  Syphilis  and  Public  Health, 
1918,  iSalmon,  Thomas  W.,  "General  Paralysis  as  a  Public  Health 
Problem,"  Amen  Jo.  of  Ins.,  1914-1915,  pp.  45-50. 


74      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [216 

the  married  men,  excepting  Jews,  among  the  immigrants 
left  their  wives  in  Europe,  and  that  nearly  85  per  cent  of 
all  the  males  of  the  Slavic  and  Italian  races  living  in  the 
United  States  are  single  or  are  married  men  living  here 
apart  from  their  wives. ^  This  has  resulted  in  conditions 
which  have  a  very  definite  bearing  upon  the  prevalence  of 
venereal  diseases."  Paresis  is  relatively  more  common  in 
cities  than  in  rural  districts,^  and  yet  among  Jewish  immii- 
grants  who  bring  their  wives  with  them  intending  to  re- 
main, but  who  also  congregate  in  the  cities,  general  paralysis 
is  less  prevalent  than  among  the  native  population.* 

Paretics  are  thus  diagnosed  because  they  become  absent- 
minded,  do  not  grasp  events  transpiring  about  them,  mis- 
take persons  and  objects,  and  lose  themselves  among 
familiar  surroundings.^  An  increased  tendency  to  fatigue 
is  frequently  among  the  first  symptoms  of  the  disease,  the 
patient  finding  his  ordinary  labor  very  difficult.  Paretics 
seldom  have  a  true  realization  of  their  condition.  On  the 
contrary,  the  patients  frequently  feel  healthier  than  pre- 
viously, or,  at  least,  they  do  not  appreciate  that  they  have 
lost  all  their  mental  powers.  In  the  patient's  behavior  there 
is  a  noticeable  bluntness  to  the  demands  of  propriety  and 
custom  which  leads  him  to  exhibitions  of  tactlessness,  lack 
of  restraint  and  even  gross  offenses,  without  his  having  the 
least  realization  thereof.     They  are  careless  of  appearance, 

*  White  and  Jelliffe,  Modern  Treatment  of  Mental  and  Nervous 
Disorders,  vol.  i,  p.  255. 

'Kraepelin  and  other  authorities  have  pointed  out  that  unmarried 
persons  seem  to  be  more  prone  to  paresis  than  the  married.  (See 
Kraepelin,  "General  Paresis,"  p.  149.) 

•Dercum,  Clinical  Manual,  p.  258. 

*  White  and  Jelliffe,  vol.  i,  p.  255. 

*  Kraepelin,  "General  Paresis,"  p.  i. 


217] 


INSANITY  AS  A  COMMUNITY  PROBLEM 


75 


have  no  sense  of  order  or  cleanliness,  boast  obtrusively, 
and  disclose  their  most  intimate  affairs/ 

The  disease  may  be  said  to  be  absolutely  fatal,  and  occa- 
sional alleged  cures  should  be  regarded  with  the  greatest 
skepticism.^  The  acute  forms  of  the  disease  are  rapidly 
fatal,  the  majority  die  in  from  eighteen  months  to  three 
years,  while  in  a  certain  few  cases  the  disease  process  isi 
very  slow  and  may  occupy  many  years.^  Of  the  99  cases 
admitted,  yi,  males  and  1 1  females  were  committed  to  state 
hospitals;  of  the  remaining  male  patients  12  were  taken 
home  by  relatives,  one,  a  well-known  actor,  was  sent  to^  a 
private  sanatorium,  where  he  died  within  a  few  days,  and 
two  died  in  the  psychopathic  ward. 

Table  4  indicates  the  years  during  which  general  paralysis: 
usually  appears,  and  brings  out  the  fact  that  about  66  per 
cent  of  the  cases  occur  between  the  ages  of  35  and  50 
years,  the  busiest  and  undoubtedly  the  most  fruitful  years 
of  the  lives  of  active  men  and  women. 


Table  4.    Age  Distribution  :  General  Paralysis 


Age. 


20-24 

25-29 

30-34 

35-39 - 

40-44 

45-49 

50-54 

55-59 

60  and  OTCT  . 

Totals 


Male. 


2 

4 

7 

17 

29 

16 

7 

3 

3 


88 


Female.  , 


Totals. 


3 
6 
II 
17 
31 
17 
8 

3 
3 


99 


1  Kraepelin,  "General  Paresis,"  pp.  3,  12,  15. 

*Ihid.,  p.  96. 

■•Dercum,  Clinical  Manual,  p.  258, 


;76       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [218 

In  the  treatment  of  general  paralysis,  institutional  care 
from  the  first  seems  to  be  pre-eminently  essential.  The 
patient  is  absolutely  unable  to  care  for  himself  and  in  a  great 
majority  of  instances  the  friends  are  equally  unable  to  care 
for  him.  As  soon  as  the  diagnosis  is  made  steps  should  be 
taken  looking  towards  the  appointment  of  a  committee  of 
his  person  and  property  or  otherwise  guarding  his  business 
interests,  if  any;  upon  investigation  such  interests  show,  al- 
most without  fail,  evidences  of  poor  management,  the  result 
of  early  manifestations  of  the  dementia/ 

The  economic  loss  to  the  State  of  New  York  on  account 
of  syphilitic  mental  disease  for  one  year  is  sufficiently  large 
to  compel  attention,  especially  since  it  is  recognized  that 
prompt  treatment  during  the  first  stages  of  syphilitic  infec- 
tion would  remove  the  danger  of  the  involvement  of  the 
nervous  system.  Dr.  Horatio  M.  Podlock,  statistician  of  the 
New  York  State  Hospital  Commission,  and  a  very  careful 
and  competent  student  of  the  subject,  has  made  the  follow- 
ing computations : 

Cost  of  maintenance  of  patients  in  institutions  ....     $471,918.72 

Loss  of  earnings  of  males 4,652,942.35 

Loss  of  earnings  of  females 273,783.92 

Total  loss $5,398,644.99 

When  it  is  remembered  that  patients  with  syphilitic  men- 
tal diseases  rarely,  if  ever,  recover  and  that  death  occurs  on 
the  average  within  two  years  of  the  time  of  entrance  in  the 
hospitals,  it  would  seem  that  himianitarian  considerations 
alone  would  impel  city  and  state  authorities  to  do  every- 
thing within  their  power  to  check  the  ravages  of  syphilis. 
Moreover,  the  enormous  economic  loss  due  to  syphilitic 
mental  diseases  furnishes  a  financial  argument  that  can  not 
well  be  ignored.^ 

'White,  Outlines  of  Psychiatry,  pp.  138-139. 

'  Pollock,  "  Economic  Loss  on  Account  of  Syphilitic  Mental  Diseases," 
Mental  Hygi-ene,  Apr.,  1918,  pp.  277-282. 


219]  INSANITY  AS  A  COMMUNITY  PROBLEM  yy 

(f)  Juvenile  General  Paralysis.  Juvenile  general  par- 
alysis is  usually  due  to  inherited  syphilis,  though  it  may 
have  its  origin  in  syphilis  acquired  in  infancy ;  compared  with 
the  adult  form  it  is  of  course,  rare/  Although  but  com- 
paratively few  cases  of  general  paralysis  in  children  have 
been  reported,  it  undoubtedly  occurs  quite  frequently  but  is 
usually  unrecognized.  The  possibility  of  general  paralysis 
should  be  thought  of  in  all  cases  of  progressive  mental  im- 
pairment in  children.-  The  single  case  referred  to  in  Table 
3  was  that  of  an  eight  year  old  boy  whose  mother,  still 
living,  had  contracted  syphilis  from  the  child's  father  six- 
teen years  prior  to  admission  of  the  youngster  to  the  hos- 
pital; the  mother  was  treated  with  mercury  for  six  years 
and  pronounced  cured ;  she  gave  birth  to  no  other  children, 
though  she  had  several  miscarriages  and  re-married  on  the 
death  of  the  child's  father.  The  patient  was  treated  with 
salvarsan  for  two  years,  as  well  as  with  mercury  for  many 
months ;  despite  the  vigorous  course  O'f  treatment  the  Was- 
serman  tests  continued  to  indicate  four  plus.  At  the  state 
hospital  staff  meeting  when  this  case  came  up  for  diagnosis 
and  discussion  the  question  as  to  whether  or  not  the  patient 
belonged  in  a  state  hospital  for  the  insane  was  considered, 
but  due  to  the  fact  that  no  other  institution  would  receive 
him,  he  still  remains  in  the  state  hospital  among  adults.* 
Kraepelin  has  pointed  out  that  among  the  cases  of  juvenile 
general  paralysis  oi  the  female  sex  coming  to  his  attention, 
the  patients  are  strikingly  often  prostitutes.* 

^  Dercum,  Clinical  Manual,  p.  259. 

*  White,  Outlines  of  Psychiatry,  p.  132. 

^  Miller,  Henry  W.  and  Achucarro,  N.,  reported  a  somewhat  similar 
case — that  of  a  boy  12  years  of  age,  illegitimate,  mother  had  syphilis 
before  birth  of  child  but  refused  to  undergo  treatment ;  also  had  several 
miscarriages.     {Arner.  lo.  of  Ins.,  Jan.,  1911,  pp.  559-5/0.) 

*  Kraepelin,  "  General  Paresis,"  p.  153. 


yS      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [220 

(g)  Lues  and  Cerebral  Syphilis.  Lues,  another  name 
for  syphilis,  presented  only  one  case  that  found  its  way  to 
the  psychopathic  ward.  There  were  five  cases  of  cerebral 
syphilis,  3  males  and  2  females.  Of  the  males,  one  was  a 
married  man  of  34,  who  had  been  treated  in  several  hos- 
pitals, and  whom  it  became  necessary  to  send  to  the  City 
Hospital,  his  mental  condition  being  sufficiently  intact  to 
render  him  a  non-committable  case.^  The  other  patient  was 
also  a  married  man,  aged  32,  who  was  being  kept  at  home' 
while  receiving  the  salvarsan  treatment  at  one  of  the  semi- 
private  hospitals.-  One  of  the  women,  aged  31,  single,  came 
from  Randall's  Island  and  died  in  the  ward  within  ten 
days  after  admission.  The  other,  a  married  woman  of 
46,  was  taken  home  by  her  husband  after  her  mental  con- 
dition had  somewhat  cleared  up.  Cerebral  syphilis  is  not  so 
often  met  with  as  general  paralysis,  at  least  in  psychopathic 
wards  or  hospitals  for  the  insane.  For  the  year  ending 
June  30,  191 8,  there  were  913  cases  of  general  paralysis 
admitted  to  the  New  York  State  Hospitals,  and  only  49 
cases  of  cerebral  syphilis  thus  admitted.^  This  is  a  grave  af- 
fection; untreated  cases  progress  more  or  less  rapidly  with 
tissue  destruction  and  often  a  fatal  termination.  Treat- 
ment, however,  if  instituted  early,  may  result  in  a  quick  and 
apparently  perfect  cure,  the  treatment  being  that  of  syphilis 
in  general.* 

(h)   Chorea.     Two  cases  of  chorea  were  admitted,  one 

^The  City  Hospital  of  the  Department  of  Public  Charities  of  the 
City  of  New  York  receives  patients  suffering  from  syphilis  in  its  various 
forms,  and  for  whom  no  other  provision  can  be  made. 

*In  this  study  when  a  patient  is  readmitted  during  the  year  to  the 
psychopathic  ward,  each  admission  is  considered  as  though  it  were  a. 
separate  admission. 

•  S.  H.  C,  30th  A.  R.,  p.  410. 

*  De  Fursac  and  Rosanoff,  pp.  442-443. 


22 1  ]  INSANITY  AS  A  COMMUNITY  PROBLEM  79 

male  and  one  female;  the  former,  a  youth  of  19  years, 
arrested,  charged  with  a  felony,  and  sent  to  the  hospital  for 
observation,  thereafter  being  returned  to  the  city  prison. 
The  second  case  was  that  of  a  married  woman  33  years  of 
age,  whom  it  was  necessary  to  commit  to  a  state  hospital. 
The  abnormal  mental  conditions  occurring  as  a  part  of 
chorea  have  been  found  to  be  an  immediate  cause  of  de- 
linquency,^ the  coincidence  in  this  single  case  being  instruc- 
tive. Huntington's  chorea,  the  diagnosis  in  the  second 
case,  usually  sets  in  between  the  ages  of  35  and  50  years. ^ 
It  is  a  chronic,  slowly  progressive,  incurable  affection,  mental 
S3miptoms  appearing  in  almost  every  case  sooner  or  later, 
with  a  weakness  of  judgment,  general  dissatisfaction  with 
surroundings,  a  growing  selfishness  and  irritability  being 
among  the  earliest  symptoms  observed.^  Studies  of  family 
histories  have  indicated  that  every  sufferer  from  this  form 
of  chorea  had  at  least  one  affected  parent,  the  obvious  way 
in  which  this  disease  can  be  eliminated  being  for  those  who 
suffer  from  it  not  to  have  children.* 

(i)  Brain  Tumor.  In  many  cases  of  brain  tumor  the 
symptoms  are  not  of  a  sufficiently  pronounced  character  to 
render  their  recognition  easy,^  though  they  are  often  limited 
to  headache,  vomiting,  vertigo,  optic  neuritis,  together  with 
certain  neurological  conditions  depending  upon  which  por- 
tion of  the  brain  is  affected.  In  about  two-thirds  of  all 
cases  mental  phenomena  are  added.*     Of  the  four  men  ad- 

'  White  and  Jelliffe,  vol.  i,  pp.  221-222. 
*De  Fursac  and  Rosanoff,  pp.  360-361. 

*  Hamilton,  A.    S.,  "A   Report   of   Twenty-seven   Cases   of    Chronic 
Progressive  Chorea,"  Amer.  lo.  of  Ins.,  Jan.,  1908,  pp.  403-474. 

*  White  and  Jelliffe,  vol.  i,  pp.  33-34. 

*  Paton,  Stevi^art,  Psychiatry,  p.  458. 
•Dercum,  Clinical  Manual,  p.  291. 


8o      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [222 

mitted,  all  were  between  35  and  40  years  of  age;  two  were 
discharged  to  the  custody  of  relatives,  one  was  committed 
to  a  state  hospital,  and  the  fourth  died  on  the  ward  within 
three  days  after  admission,  having  been  brought  to  the  hos- 
pital in  a  moribund  condition. 

(j)  Cerebral  Hemorrhage.  The  single  case  of  cerebral 
hemorrhage  was  that  of  a  man  43  years  of  age,  who  had 
been  struck  on  the  head  by  a  bar  of  iron  while  at  his  work. 
He  left  the  hospital  within  a  day  after  admission,  and  his 
condition  had  not  fully  cleared  up  months  later,  especially 
as  it  was  aggravated  by  heavy  drinking  of  alcoholic  liquors. 
He  was  not  considered  a  proper  case  for  commitment. 

(k)  Alcoholkm.  The  question  of  alcohoHsm  and  the 
problems  it  creates  has  been  discussed  in  preceding  pages. 
Many  writers  have  pointed  out  that  Jews  contribute  but  a 
small  percentage  of  alcoholic  psychoses  to  the  total  admis- 
sions to  state  hospitals.^  Of  the  22  admissions  for  which 
alcohol  was  the  essential  cause,  but  3  cases  presented  an 
acute  alcoholic  psychosis,  these  being  the  only  alcoholics  to 
be  subsequently  committed  to  a  hospital,  one  to  a  private 
sanatorium,  2  to  a  state  hospital,  out  of  a  total  of  828  com- 
mitments," while  5.2  per  cent  of  first  admissions  for  the 
state  as  a  whole  presented  alcoholic  psychoses.* 

(1)  Narcotic  Drug  Poisoning.  During  the  past  few 
years  the  number  of  cases  of  narcotic  drug  poisoning  has 
increased  very  perceptibly  and  the  nine  cases  of  drug  poison- 
ing including  one  of  toxic  delirium,  represent  only  those 
whom'  it  was  found  advisable  temporarily  to  detain  in  the 

^Fishberg,  Maurice,  The  Jews,  pp.  273-274,  342-43;  Kirby,  George  H., 
"Race  and  Alcoholic  Insanity,"  Jo.  Anier.  Med.  Assn.,  July  i,  1911,  pp. 
9-11;  Swift,  H.  M.,  "Insanity  and  Race,"  Amer.  Jo.  of  Ins.,  July,  1913, 
p.  152. 

*  See  table  14,  "  Disposition  of  Patients." 

» S.  H.  C,  30th  A.  R.,  p.  285. 


223]  INSANITY  AS  A  COMMUNITY  PROBLEM  gl 

psychopathic  wards.  ^  None  of  these  cases  required  com- 
mitment to  a  state  hospital  though  the  existence  of  proper 
and  adequate  facilities  would  have  helped  materially  in  the 
treatment  of  these  and  many  other  patients  suffering  simil- 
arly. 

(m)  Infection  Exhaustion  Psychosis.  All  factors  cap- 
able of  bringing  about  rapid  and  profound  exliaustion  of 
the  organism  occur  in  the  etiology  of  primary  mental  con- 
fusion; physical  and  mental  stress,  painful  and  prolonged 
emotions,  but  esj^ecially  grave  somatic  affections.  The 
puerperal  state,  through  the  exhaustion  which  it  entails  as 
well  as  through  the  nutritive  disorders  and  infections  by 
which  it  is  sometimes  complicated ;  infectious  diseases 
(typhoid,  influenza,  cholera)  ;  profuse  hemorrhages,  etc.  are 
among  the  causes  frequently  found  in  the  historj^  of  the 
disease.  Out  of  a  total  of  13  female  cases  of  infection  ex- 
haustion psychosis,  6  resulted  from  the  puerperal  state,  5 
from  pneumonia,  i  from  chronic  cardiac  disease,  i  from 
blood  poisoning.  Four  male  cases  were  recorded,  i  re- 
sulting from  pulmonary  tuberculosis.  2  from  pneumonia, 
and  I  from  empyema. 

(n)  Manic  Depressive  Insanity.  The  largest  single 
group  of  cases  to  be  admitted  was  the  manic  depressive 
which  totaled  356  patients,  or  about  31  per  cent  of  the 
total  admissions.  The  term  "  manic  depressive  insanity  " 
was  introduced  by  Kraepelin  -  and  is  in  general  use  at  pre- 
sent to  signify  cases  in  which  the  attacks  present  a  double 
characteristic :   a  tendency  towards   recover}-   witliout   in- 

'For  a  discussion  of  the  problem  of  drug  addiction  in  New  York, 
with  special  reference  to  Jewish  drug  addicts,  see  Goldberg,  Jacob  A., 
The  Drug  Habit  as  a  Social  and  Legislative  Problem  (M.  A.  thesis, 
Columbia  Univ.,  1916). 

'Dercum,  Clinical  Manual,  p.  64;  also,  Kraepelin,  Lehrbuch  der 
Psychiatrie.  band  ii. 


82      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [224 

tellectual  eiifeeblement  and  a  tendency  toward  recurrency.^ 
The  principal  cause  is  hereditary  taint,  and  it  is  noteworthy 
that  this  disease  is  often  found  in  famihes,  the  constitutional 
condition  as  the  basis  on  which  it  develops  appearing  to  be 
directly  transmitted."  From  a  symptomatic  standpoint  the 
attacks  are  of  three  types:  manic,  presenting  a  flight  of 
ideas,  irritability,  and  motor  excitement;  depressed,  with 
psychic  inhibition,  and  a  painful  emotional  state  associated 
with  indifference;  mixed,  in  which  a  period  of  depression 
and  period  of  excitement  alternate,  the  transition  being 
either  sudden  or  gradual."  It  has  been  found  that  this 
psychosis  occurs  more  frequently  in  females  than  in  males,, 
about  in  proportion  of  2  to  i.*  Of  the  cases  under  con- 
sideration, the  males  in  this  group  accounted  for  24.8  per 
cent  of  the  total  male  admissions,  whereas  for  the  females, 
41.6  per  cent  of  the  admissions  were  classified  as  manic 
depressive  insanity.  The  individual  attacks  vary  in  dura- 
tion from  a  few  days  to  several  months,  some  attacks,  how- 
ever, being  greatly  prolonged.^  Recovery  from  the  single 
attack  is  the  rule,  while  the  likelihood  of  subsequent  attacks 
is  usually  presimied  to  be  quite  certain.  The  prognosis  of 
the  disease  is  bad  as  to  ultimate  recovery  though  good  for 
the  separate  attacks.^ 

*  De  Fursac  and  Rosanoff,  p.  293 ;  also  White  and  Jelliffe,  vol.  i,  p.  535. 

'White,  Wm.  A.,  Outlines  of  Psychiatry,  p.  99;  Peterson,  Frederick, 
Mental  Diseases,  1899,  p.  694,  holds  that  hereditary  taint  is  found  in 
75  per  cent  and  degenerative  stigmata  in  20  per  cent  of  cases. 

'White  and  Jelliffe,  vol.  i,  pp.  529-589  present  a  thorough  discussion 
of  this  psychosis. 

*Dercum,  p.  63. 

'A  most  interesting  study  of  a  case  of  manic  depressive  insanity 
lasting  for  many  months  is  described  by  Clifford  W.  Beers  in  "A  Mind 
that  Found  Itself,"  being  a  detailed  story  of  the  attack  suffered  by 
Mr.  Beers. 

•Readmissions  to  the  state  hospitals  are  indicated  in  table  22. 


225]  INSANITY  AS  A  COMMUNITY  PROBLEM  83 

In  the  accompanying  table,  the  manic  and  depressed 
cases  are  not  separated,  the  total  admissions  having  been 
102  males,  103  females;  of  mixed  psychoses  35  were  males 
and  54  females.  It  is  often  difficult  to  draw  a  sharp  line 
between  borderline  cases,  and  these  have  been  entered  as 
allied  to  manic  depressive  insanity,  30  males  and  32  females/ 
The  following  table  points  out  the  final  disposition  of  the 
cases  in  this  group. 

Tabi£  5.    Disposition  of  M.  D.  I.  Patients 


Disposition. 

Male. 

Female. 

Totals. 

135 

II 

2 

19 

159 
'5 

294 
26 

Returned  to  City  Prison 

Discharged 

2 
34 

Totals 

167 

189 

356 

These  figures,  indicating  a  large  number  of  commitments 
and  but  a  few  discharges,  usually  of  borderline  cases  or 
those  whom  relatives  insisted  on  taking  home,  help  bring 
to  the  fore  a  marked  weakness  in  the  system  of  care  and 
treatment  of  the  insane.  Many,  if  not  a  majority  of  these 
patients  would  have  recovered  from  the  attack  if  cared  for 
in  a  psychopathic  hospital  for  a  period  oi  a  few  weeks.  In- 
stead, they  were  sent  to  an  overcrowded  and  undermanned 
state  hospital  in  which  facilities  for  the  treatment  of  these 
so-called  acute  cases  are  below  the  necessary  minimum.  It 
is  because  of  the  lack  of  an  essential  link  (psychopathic 
hospital)    in  the  state  hospital  system  that  much  of  the 

*On  the  early  differential  diagnosis  between  dementia  praecox  and 
manic  depressive  insanity,  vide  Dercum,  Penn.  Med.  Jo.,  Aug.,  191 7, 
p.  765. 


84       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [226 

overcrowding  is  due.  Given  such  hospitals  in  different 
parts  of  the  state,  a  marked  percentage  of  the  present  over- 
crowded conditions  would  be  eliminated  within  a  short 
space  of  time. 

The  distribution  of  cases  of  manic  depressive  insanity  ac- 
cording to  age  was  as  follows  : 

Table  6.    Age  Distribution  of  M.  D.  I.  Patients 
Age. 


Under  15.  .. 

15-19  

20-24  

25-29  

30-34  

35-39  

40  and  over . 

Totals 


Male. 


167 


Female. 


Totals. 


3 

4 

7 

»S 

32 

47 

39 

45 

84 

32 

32 

64 

20 

29 

49 

23 

21 

44 

35 

26 

61 

356 


As  in  the  cases  of  dementia  praecox  (Table  8),  the  out- 
standing feature  of  the  above  figures  is  the  comparative 
youthfulness  of  the  majority  of  cases.  In  this  group  there 
is  a  larger  proportion  of  those  over  30  years  of  age,  due  to 
a  number  of  causes,  among  those  being  the  fact  that 
dementia  praecox  psychoses  develop  earlier  than  manic  de- 
pressive attacks,  and  also  to  the  fact  that  many  of  the  more 
serious  stresses  in  life  do  not  come  till  after  the  thirtieth 
year,  heredity  and  stress  being,  as  aforementioned,  the  most 
important  causes  of  manic  depressive  psychoses.  Over  82 
per  cent  of  the  above  cases  were  under  40  years  of  age,  in 
the  very  prime  of  life,  and  irrespective  of  the  sadness  and 
misery  resulting,  the  economic  loss  to  society  as  a  result  of 
this  must  in  any  event  be  very  large. 

(o)  Involutional  Melaiicholm.  Involutional  melancholia, 
the  diagnosis  in  t  male  and  5  female  cases,  occurs  chiefly 


227]  INSANITY  AS  A  COMMUNITY  PROBLEM  85 

after  forty-five  years  of  age.  The  ages  of  the  six  patients 
were  42,  45,  53,  54,  56  and  60  years.  The  causes  of  this 
disease  are  not  well  known,  though  a  neuropathic  heredity 
has  been  found  in  about  60  per  cent  of  the  cases.  ^  Among 
the  symptoms  are  anorexia,  insomnia,  irritability,  unwar- 
ranted pessimism,  a  tendency  to  rapid  fatigue,  with  often 
a  marked  depression,  leading  in  a  number  of  cases  to  suicide, 
unless  closely  guarded.  It  was  found  necessary  to  commit 
each  of  the  six  patients  to  a  state  hospital. 

(p)  Dementia  Praecox.  Dementia  praecox,  one  of  the 
cormnonest  forms  of  mental  disease,  is  a  psychosis  essen- 
tially of  the  period  of  puberty  and  adolescence,  character- 
ized by  mental  deterioriation  tending  to  progress,  though 
frequently  interrupted  by  remissions.  According  to  Krae- 
pelin  sixty  per  cent  of  all  cases  of  dementia  praecox  begin 
before  the  twenty-fifth  year,  the  simple  form  usually  start- 
ing between  the  fifteenth  and  twenty-fifth  year,  the  paranoid 
form  beginning  around  the  end  of  the  second  decade,  and 
one-half  of  the  katatonic  cases  setting  in  around  the  twenty- 
fifth  year.^  It  is  to  Kraepelin  that  much  credit  belongs  for 
the  great  interest  taken  in  the  subject  of  dementia  praecox 
in  recent  years,  due  to  the  serious  effort  on  his  part  to  clear 
up  the  early  confusion.^  There  were  212  males  and  117 
females  admitted  to  the  psychopathic  wards  in  one  year, 
the  largest  number  being  among  the  hebephrenic  form,  of 
whom  1 18  males  and  34  females  came  to  the  hospital.  The 
real  significance  and  importance  of  the  cases  of  dementia 
praecox  from  the  point  of  view  of  hospital  expenditures  and 
management  especially,  may  be  gathered  from  the  fact 
that  on  July  i.  191 6,  53.81  per  cent  of  the  patients  in  all  the 

•  De  Fursac  and  RosanoflF,  p.  324. 

*Jacoby,  Unsound  Mind,  p.  197. 

'Hall,  G.  Stanley,  Adolesceiue,  1908,  vol.  i,  p.  301. 


86       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [228 

state  hospitals  for  the  insane  in  New  York  were  diagnosed  as 
dementia  praecox,  whereas  the  psychosis  that  stood  next 
highest  was  the  manic  depressive  group  and  the  alHed  forms 
thereof,  of  which  there  were  less  than  10  per  cent.^  In  191 7 
the  proportion  of  dementia  praecox  cases  was  53.8  per  cent," 
and  in  1918  it  rose  to  58.7  per  cent."  The  financial  burden 
which  the  state  must  carry  in  caring  for  these  patients  is 
increasing  from  year  to  year,  and  the  need  to  find  a  way 
out  is  very  urgent,  since  with  better  care,  improved  diet  and 
housing  conditions,  the  length  of  life  of  these  patients  in  the 
institutions  tends  to  increase,  and  thus  the  percentage  of 
such  patients  will  naturally  increase  as  time  goes  on. 

There  are  many  difficulties  however,  in  discovering  ways 
and  means  of  curing  or  so  improving  the  mental  condition 
of  dementia  praecox  patients  that  they  may  safely  be  dis- 
charged from  custody.  To  begin  with,  only  the  outward 
manifestations  of  the  disease  are  known  with  any  degree 
of  accuracy,  whereas  the  causes  are  almost  completely  un- 
known.* It  is  generally  agreed  that  probably  the  most  im- 
portant question  in  contemporary  psychiatry  is  the  nature 
of  dementia  praecox,  that  is,  the  genesis  of  the  disease  pro- 
cess.^ There  have  been  .miany  theories  advanced  as  to  the 
cause  and  nature  of  the  disease.  Some  have  held  that 
heredity  is  to  be  regarded  as  the  essential  cause  of  the 
disorder ;  ^   that    heredity    plays    an    uncertain    role    in    its 

^Psychiatric  Bulletin,  Oct.,  1917.  p.  456. 

» S.  H.  C,  29th  A.  R.,  p.  440. 

» S.  H.  C,  30th  A.  R..  p.  292. 

*Tanzi,  Eugenio.  Textbook  of  Mental  Diseases,  1909,  pp.  663-665. 

^Coriat,  Isidor  H.,  "  Psychopathology  of  Dementia  Praecox,"  Amer. 
Jo.  of  Ins.,  Jan.,  1917.  pp.  670-671 ;  Southard,  E.  E.,  "A  Study  of 
Dementia  Praecox,"  Amer.  Jo.  of  Ins.,  July.  1910,  pp.  124-125. 

•De  Fursac  and  RosanofF,  p.  280. 


229]  INSANITY  AS  A  COMMUNITY  PROBLEM  g/ 

etiology ;  ^  that  abnormal  functions  of  internal  glands  are 
responsible  for  the  disorder;  -  that  dementia  praecox  is  de- 
pendent upon  an  auto-intoxication  produced  by  poisons 
which  are  elaborated  in  the  sexual  organs  and  which  are 
especially  injurious  to  the  brain;"  that  infectious  diseases, 
especially  influenza,  may  become  the  starting  point  of  de- 
mentia praecox.*  From  the  varied  and  conflicting  views 
it  is  quite  apparent  that  much  still  remains  to  be  discovered 
regarding  dementia  praecox,  though  certain  more  or  lesa 
definite  facts  concerning  the  various  manifestations  of  the 
different  forms  of  the  disease  have  been  determined.'^ 

Parents  and  relatives  of  children  who'  begin  to  show 
symptoms  of  dementia  praecox  rarely  understand  the 
reasons  for  the  apparent  laziness,  their  inability  tO'  apply 
themselves  to  their  studies  or  work,  the  irritability  and 
failure  to  join  in  the  games  and  sports  of  their  fellows.* 

^  White,  Outlines  of  Psychiatry,  p.  140. 

^  Hoch,  August,  "  Precipitating  Mental  Causes  in  Dementia  Praecox," 
Amer.  Jo.  of  Ins.,  Jan.,  1914,  p.  637;  Auer,  E.  Murray,  "  Disease  of  the 
Glands  of  internal  iSecretion."  Amer.  Jo.  of  Ins.,  Oct.,  1914,  p.  498. 

*  Taiazi,  op.  cit.,  pp.  663-665.  quotes  Kraepelin  on  this  point ;  Tanzi 
disagrees  with  this  theory. 

*  Paton,  Psychiatry,  p.  405. 

*  Abbott,  E.  S.,  "Meyer's  Theory  of  the  Psychogenic  Origin  of  De- 
mentia Praecox,"  Amer.  Jo.  of  Ins.,  July,  191 1,  pp.  15-22,  makes  the 
observation  that  causes  are  multiple,  and  so  diligent  search  is  necessary, 
not  only  along  psychobiological  lines,  as  advised  by  Meyer,  but  in  others, 
including  all  possible  organic  changes  as  well.  For  a  further  discussion 
of  Meyer's  theory  see  Psychological  Clinic,  vol.  ii,  p.  92  et  seq.;  Amer. 
Jo.  of  Psychology,  vol.  xxi,  p.  395  et  seq. 

•Flexner,  Bernard  and  Baldwin,  Roger  N.,  Juvenile  Courts  and  Pro- 
bation, 1914,  pp.  41-42,  advise  the  establishment  of  psychopathic  clinics 
attached  to  public  schools  in  order  to  discover  these  cases  at  an  early 
stage  of  their  illness.  iMacCurdy,  John  T.,  "  Psychiatric  Clinics  in  the 
Schools,"  Amer.  Jo.  of  Public  Health,  vol.  vi,  no.  xii,  pp.  1265-1270, 
points  out  why  psychiatric  cHnics  in  the  schools  may  offer  reasonable 
hope  of  reducing  insanity  in  the  latter  life  of  the  pupils.  Vide  Healy, 
William,  The  Individual  Delinquent,  1915,  pp.  66-67. 


88      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [230 

The  result  is  that  these  potential  cases  of  dementia  praecox 
are  kept  at  home  until  the  disease  is  fully  developed  and  the 
patience  of  their  relatives  is  exhausted,  when  they  are 
brought  to  the  psychopathic  ward  for  commitment  to  a  state 
hospital.  The  following  figures  show  the  large  proportion 
of  the  cases  that  were  committed : 

Table  7.    Disposition  of  Cases  of  D.  P. 


Disposition. 

Male. 

174 
6 

4 
I 

27 

Female. 

Totals. 

2 
I 

9 
117 

279 

4 

36 

Totals 

212 

329 

It  has  been  computed  that  dementia  praecox  involves  annual 
direct  and  indirect  losses  to  the  State  of  New  York  of  more 
than  $10,000,000.^  This  is  largely  so  because  these  case^ 
remain  in  the  state  hospitals  for  an  average  of  16  years, 
most  of  them  being  of  wage-earning  age.  as  seen  from  the 
figures  that  follow : 

Table  8.    Age  Distribution  of  D.  P.  Patients 


*  Pollock,  "  Dementia  Praecox  as  a  Social  Problem," 
Quarterly,  Aug.,  1918. 


State  Hospital 


231]  INSANITY  AS  A  COMMUNITY  PROBLEM  89 

The  fact  that  the  recovery  rate  of  dementia  praecox  patients 
in  state  hospitals  is  very  low/  is  an  additional  contributing 
factor  to  the  high  percentage  of  such  cases  in  institutions, 
outnumbering,  as  they  do,  all  other  patients  put  together. 
Merely  to  herd  these  cases  in  state  hospitals  is  a  hopeless 
task  and  further  steps  must  be  taken  either  by  the  state  or 
by  private  agencies,  or  by  both,  to  find  ways  and  means  of 
solving  the  problem  of  proper  and  advisable  methods  to  be 
pursued  in  the  study,  care  and  treatment  of  this  group  of 
the  state's  charges. 

(q)  Paranoid  Cofiditiotis.  Paranoia  is  a  chronic  pro- 
gressive psychosis  occurring  mostly  in  early  adult  life,  be- 
tween the  ages  of  25  and  40  years,  characterized  by  the 
gradual  development  of  a  stable  progressive  system  of  de- 
lusions without  marked  mental  deterioration,  clouding  of 
consciousness,  or  disorder  of  thought,  will  or  conduct.^ 
The  disease  is  not  common,  and  constitutes  only  a  small 
percentage  of  the  cases  admitted  to  insane  asylums.^  Men 
are  more  often  afflicted  than  women.  It  develops  on  a 
defective  constitutional  basis,  either  congenital  or  acquired, 
defective  heredity  existing  in  a  very  large  percentage  of  the 
cases.*  The  development  of  the  psychosis  is  often  slow 
and  gradual,  though  it  may  develop  very  rapidly,  almost 
suddenly.^     The  patient  will  usually  change  in  dispositicm, 

•  Pollock,  "A  Statistical  View  of  Mental  Disease  in  the  New  York 
State  Hospitals"  Psychiatric  Bulletin,  Oct.,  191 7. 

*  Diefendorf ,  op.  cit.,  p.  420. 

•In  1918  only  4.4  per  cent  of  the  patients  in  the  New  York  State 
Hospitals  were  suffering  from  paranoiac  conditions.  (S.  H.  C,  30th 
A.  R.,  p.  292.) 

'  Dercum,  Clinical  Manual,  maintains  that  heredity  is  responsible  in 
85  to  90  per  cent  of  cases,    (p.  134.) 

'A  difference  of  opinion  exists  as  to  the  rapidity  of  onset.  Thus 
De  Fursac  and  Rosanoff  (p.  287)  maintain  that  the  rapid  development 
of  the  disease  is  more  frequent,  whereas  Diefendorf  (p.  424)  holds  that 


go      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [232 

become  somewhat  irritable,  grumbling,  very  suspicious,  and 
easily  discontented.  There  were  but  10  such  cases  ad- 
mitted, 8  males  and  2  females;  7  were  taken  home  by  re- 
latives and  3  committed  to  state  hospitals/  Practically  all 
writers  on  the  subject  agree  as  to  the  chronicity  and  in- 
curability of  paranoia ;  ^  and  though  a  few  recoveries  have 
been  reported,  a  critical  examination  of  these  cases  hasi 
resulted  in  a  disagreement  as  to  the  diagnosis." 

(r)  Epilepsy  and  Mental  Deficiency.  Among  the  re- 
mainder of  the  Jewish  cases  brought  to  the  psychopathic 
ward,  there  were  32  male  and  14  female  epileptics,  and  33 
male  and  16  female  mental  defectives  of  all  kinds.  Bad 
heredity  is  by  far  the  most  common  and  important  cause 
of  the  above  mental  conditions,  though  parental  alcoholism 
and  parental  syphilis  are  additional  important  factors.* 
Most  of  the  patients  of  this  group  were  brought  to  the 

the  onset  is  very  gradual,  extending  sometimes  over  years.  If  the 
Freudian  view  is  taken,  namely,  that  paranoia  is  a  defense  psychosis 
d'Ctermined  by  the  nature  of  the  painful  reminiscences  repressed,  then 
the  latter  viewr  must  be  accepted.  Fide  Freud,  E.,  Selected  Papers  on 
Hysteria  and  other  Psychoneuroses,  1909,  pp.  165-174. 

*Kirby,  George  H.,  "Dementia  Praecox,  Paraphrenia  and  Paranoia," 
Amer.  Jo.  of  Ins.,  vol.  Ixxi,  p.  359.  states  that  paranoia  is  the  outgrowfth 
of  personal  difficulties  in  the  adaptation  to  the  environment  of  abnorm- 
ally constituted  personalities,  and  that  most  of  these  cases  are  able  to 
get  along  in  society  and  their  commitment  is  usually  not  necessary. 

•  Abbott,  E.  S.,  "What  is  Paranoia,"  Amer.  Jo.  of  Ins.,  vol.  Ixxi,  p.  41. 

*Bjerre,  Paul,  History  and  Practice  of  Psychoanalysis  (pp.  205-246), 
presents  the  case  of  a  paranoical  system  of  persecution  of  ten  years 
standing  which  he  claims  was  entirely  broken  up  and  not  a  trace  of 
recurrence  appeared  six  years  after  conclusion  of  the  treatment,  which 
followed  the  psychoanalytic  method  and  was  extended  over  a  long 
period  of  time.  White,  Principles  of  Psychiatry,  p.  97,  believes  there 
are  possibilities  of  accomplishing  cures  by  attacking  the  problem  thera- 
peutically, probably  along  the  Hnes  followed  by  Bjerre. 

*Tredgold,  A.  F.,  Amentia,  offers  a  comprehensive  study  of  this  group 
of  cases. 


233]  INSANITY  AS  A  COMMUNITY  PROBLEM  gi 

hospital  either  because  they  were  sent  by  the  courts  for 
mental  examination  after  arrest  for  some  crime,  or  be- 
cause relatives  could  no  longer  keep  them  at  home.  Only 
a  few  of  these  patients  were  committed  to  a  state  hospital, 
this  step  being  taken  only  when  they  suffered  from  a 
psychosis  in  addition  to  the  other  condition'.  A  majority 
of  them  should  have  been  placed  in  institutions  for  the 
epileptic  or  feebleminded  years  prior  to  their  arrest  or 
hospital  admission.^  However,  due  to  the  failure  of  early 
diagnosis  as  well  as  to  the  overcrowded  institutional  con- 
ditions, these  patients  have  been  permitted  to  wander  about 
the  streets,  fall  into  criminal  ways,  eventually  to  be  sent 
to  jails  and  prisons  instead  of  to  farm  or  industrial  colonies 
in  which  they  properly  belong."  Until  the  state  completes 
a  comprehensive  plan  for  the  care  of  all  such  cases  needing 
custodial  or  other  similar  care  and  treatment,  no  abatement 
of  hospital  and  prison  admissions  of  this  group  can  pro- 
perly be  expected. 

(s)  Psychoneuroses.  There  were  4  cases  of  psycho- 
neuroses,  few  of  which  find  their  way  to  the  psychopathic 
wards  and  state  hospitals,  though  neuroses  constitute  one  of 
the  most  wide-spread  forms  of  disease ;  ^  of  hysteria  i  male 
and  9  female  patients,  and  of  hysterical  episode  i  male  and 
I  female;  of  hypomanic  i  female;  of  various  undifferen- 

^Gesell.  Arnold,  "Mental  Hygiene  and  the  Public  School,"  Mental 
Hygiene,  Jan.,  1919,  pp.  4-10,  suggests  the  means  to  be  employed  in 
public  schools  in  order  to  pick  out  those  children  who  are  predisposed 
to  mental  or  nervous  conditions.  Campbell,  C.  Macfie,  "A  City  School 
District  and  Its  Subnormal  Children,"  Mental  Hygiene,  April,  1918, 
pp.  232-244,  offers  suggestions  for  constructive  work  with  such  children. 

*Glueck,  Bernard,  "Types  of  DeHnquent  Careers,"  Mental  Hygiene, 
April,  1917,  pp.  171-19S,  shows  how  bad  heredity  and  mental  defective- 
ness may  result  in  delinquent  careers.  Vide  Glueck,  "Concerning 
Prisoners,"  Mental  Hygiene,  April,  1918,  pp.  177-218.  Glueck,  Studies 
in  Forensic  Psychiatry,  1916. 

"White  and  Jelliffe,  vol.  i,  p.  333. 


92      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [234 

tiated  depressions,  i  male  and  17  females;  and  of  transitory 
confusion  3  males  and  2  females.  Eight  cases,  7  males  and 
I  female  were  unclassified,  due  largely  to  the  fact  that  they 
left  the  psychopathic  ward  in  the  custody  of  relatives  be- 
fore the  examination  could  be  made  or  completed. 

(t)  ConstiHUional  Inferiority.  Constitutional  inferior- 
ity is  a  term  applied  to  those  who  show  a  mildly  dwarfed 
mental  endowment  with  limited  attainments  and  an  in- 
ability to  grapple  with  the  problems  of  everyday  life.^ 
These  cases  are  subject  to  episodes  of  excitement  and  de- 
pression, often  developing  paranoid  states  of  a  more  or 
less  transitory  character.  They  frequently  commit  crimes 
and  are  essentially  chronic  in  character,  so  far  as  duration 
is  concerned.  Many  of  them  are  never  admitted  to  hos- 
pitals for  the  insane,  but  drift  into  prisons  and  reforma- 
tories, or  other  custodial  institutions.^  Their  main  dif- 
ficulty seems  to  be  in  adjusting  themselves  to  their  environ- 
ment but  they  cannot  be  regarded  as  mentally  sick  accord- 
ing to  the  definition  of  the  code.  It  is  for  this  reason  that 
so  many  of  them  never  reach  a  state  hospital,  and  still  in 
the  various  institutions  to  which  they  are  sent  they  are  un- 
fortunately misunderstood  and  misjudged — the  only  solu- 
tion of  the  difficulty  seeming  to  be  the  creation  of  a  special 
institution  for  those  suffering  from  constitutional  inferior- 
ity.^ 

Twenty-five  cases  admitted  to  the  wards  were  foimd  not 
to  be  insane  and  discharged  to  their  own  custody  or  turned 
over  to  police  and  court  officials  by  whom  they  had  been 

'Karpas,  Morris  J.,  "Constitutional  Inferiority,"  Jo.  Amer.  Med. 
Assn.,  Dec.  16,  1916,  p.  1831,  presents  an  analysis  of  the  concept  of 
constitutional  inferiority,  especially  regarding  the  method  of  diagnosis 
of  such  cases. 

*  White  and  JelHffe,  vol.  i,  pp.  846-847. 

'Bellevue  and  Allied  Hospitals,  Annual  Report,  1912,  p.  64. 


235] 


INSANITY  AS  A  COMMUNITY  PROBLEM 


93 


brought  for  mental  examination  upon  order  of  a  court. 
This  completes  the  analysis  from  the  point  of  view  of 
diagnosis  of  the  1,127  Jewish  cases  admitted  to  Bellevue 
Hospital  psychopathic  wards.  What  follows  immediately 
considers  this  group  from  different  angles  so  that  as  com- 
plete a  mental  picture  as  possible  may  be  obtained.  In  this 
way,  it  is  hoped,  the  needs  of  the  insane  and  the  respon- 
sibility of  the  community  towards  them  may  be  better  un- 
derstood and  realized,  and  steps  taken  to  alleviate  and 
remedy  conditions  that  should  no  longer  be  permitted  to 
exist. 

Table  9.    Number  of  Admissions 


Male. 

Female. 

Total. 

543 
130 

385 

69 



454 

928 
199 

Readmissions 

Totals 

673 

1,127 

It  is  often  difficult  to  ascertain  whether  or  not  certain 
patients  admitted  to  the  psychopathic  wards  are  readmis- 
sions to  these  wards.  The  figures  presented  in  Table  g, 
showing  17.6  per  cent  readmissions  are  imdoubtedly  low, 
especially  in  view  of  the  much  higher  percentage  of  read- 
missions  recorded  in  the  state  hospitals,^  particularly  as  re- 
gards the  Jewish  patients  under  consideration.  A  number 
of  these  readmissions  were  parole  cases  from  the  state 
hospitals;  others  had  been  patients  in  state  institutions 
whose  parole  period,  formerly  only  six  months  but  now,  in 
s«me  instances  as  long  as  one  year,  had  expired,  thus  male- 
's. H  C,  30th  A.  R..  p.  278. 


94       SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE       [236 

ing  it  necessary  to  have  them  recommitted.  The  question 
as  to  why  so  large  a  percentage  of  cases  relapsed  after  dis- 
charge from  the  state  hospitals  will  be  considered  in  detail 
in  another  chapter. 

VII.    MARITAL  CONDITION 

In  the  following  table  (Table  10)  the  marital  condition  of 
the  patients  is  presented.  There  were  almost  twice  as  many 
single  as  married  males;  whereas,  of  female  patients,  there 
were  actually  fewer  single  than  married.  The  large  percent- 
age of  single  persons  amtmg  the  insane  enumerated  by  the 
United  States  Census  of  1910,  showing  63.5  per  cent  male 
and  41.7  per  cent  female,  compared  to  60.3  per  cent  male 
and  44.5  per  cent  female  in  Table  10,  should  not  be  inter- 
preted as  indicating  that  the  single  are  more  liable  to  be- 
come insane  than  the  married.  It  means  rather,  that  the  in- 
sane as  compared  with  the  normal  are  less  likely  to  marry. 
That  the  percentage  of  single  persons  is  smaller  for  fe- 
males than  for  males,  both  among  the  insane  and  the 
general  population,  is  due  to  the  fact  that  women  marry 
at  a  younger  age  than  men.  The  psychoses  which  are 
largely  responsible  for  the  majority  of  cases  of  insanity  do 
not  as  a  rule  develop  until  after  the  eighteenth  year,  except 
in  the  cases  of  dementia  praecox,  hebephrenic  form.  By 
this  time  in  many  cases,  the  females  are  married  and  for  that 
reason  psychoses  were  found  to  have  developed  in  an  un-< 
duly  large  number  of  young  women  whose  marriage  was  a 
matter  of  but  a  short  time.  The  added  burdens  of  house- 
hold care,  of  gestation,  pregnancy,  and  lactation,  have  caused 
the  onset  of  psychoses  in  persons  as  to  whose  good  mental 
condition  there  was  no  question  prior  to  marriage ;  at  least 
the  nearest  relatives  knew  of  no  mental  abnormality,  indi- 
cated or  latent. 

The  comparatively  large  number  of  married  men   and 


237]  INSANITY  AS  A  COMMUNITY  PROBLEM  95 

women,  many  of  them  with  dependent  children,  presents  an 
important  social  problem.  The  majority  of  these  patients 
were  between  the  ages  of  20  and  40  years,  and  the  commit- 
ment of  a  father  or  mother  to  an  institution  for  the  insane 
left  a  family,  in  many  cases,  in  straightened  circumstances. 

Table  10.     Marital  Condition 


Single 

Married 

Widowed . . . . 
Divorced . . . . 

Totals 


Male. 


406 

234 

25 

8 


673 


Female. 


190 
201 

53 
10 


454 


Total. 


596 

435 
78 
18 


1,127 


With  but  very  few  exceptions,  the  social  status  of  nearly  all 
the  patients  was  that  of  working  people  whose  only  source 
of  income  was  what  they  themselves  earned  from  week 
to  week,  or  what  relatives  contributed  out  of  meagre  in- 
comes. Under  such  conditions,  the  commitment  of  an  un- 
married young  man  or  woman  has  in  many  cases  meant 
a  reduction  in  the  family  income,  whereas  in  cases  of  mar- 
ried persons  more  serious  adjustments  have  to  be  made,  this 
often  being  possible  only  through  the  financial  aid  of  a 
social  or  relief  agency.  The  kind  and  amount  of  assistance 
to  be  rendered  to  such  families  depends  on  whether  the 
father  or  the  mother  has  been  committed:  the  number  and 
age  of  the  children,  if  any;  the  financial  resources  of  the 
family,  and  the  assistance  to  be  expected  from  relatives. 
Often  the  most  important  factor  is  the  matter  of  the 
diagnosis  of  the  patient;  if  a  recovery  may  reasonably  be 
expected  within  a  few  weeks  or  months,  emergency  assist- 
ance will  usually  be  sufficient  to  keep  the  family  together; 


96 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[238 


otherwise  a  more  definite  program  of  relief  must  be  outlined 
and  carried  out. 


VIII.    NATIVITY 

In  the  United  States,  and  esj>ecially  in  New  York  State, 
the  question  of  immigration  in  relation  to  insanity  presents 
a  problem  of  great  magnitude.  Of  the  total  number  of  in- 
mates of  insane  asylums  on  January  i,  1910,  according  to 
the  enumeration  of  the  Thirteenth  Census,  28.8  per  cent 
were  whites  of  foreign  birth,  and  of  the  persons  admitted 
to  such  institutions  during  the  year  1910,  25.5  per  cent  were 
of  this  class. ^  Of  the  total  population  of  the  United  States 
in  1 910  the  foreign-born  whites  constituted  14.5  i>er  cent." 
The  number  of  foreign  born  admitted  to  the  New^  York 
State  Hospitals  for  the  year  191 8  was  44.5  per  cent  of  the 
total  admissions ;  those  of  foreign  parentage  constituted  59.8 
per  cent  and  those  of  mixed  parentage  11. o  per  cent.* 
From  this  it  seems  that  for  the  country  as  a  whole  and  for 
New  York  State  in  particular  the  foreign  bom  have  an 
unduly  large  representation  in  insane  asylums.  However, 
it  should  be  remembered  that  most  cases  of  insanity  occur 
after  the  eighteenth  year,  and  that  the  difference  in  age 
distribution  which  exists  between  the  native  and  foreign- 
bom  parts  of  the  population  accounts  largely,  but  not 
wholly,  for  the  difference  in  the  proportion  of  insane  hos- 
pital admissions.* 

'  Insane  and  Feebleminded  in  Institutions,  U.  S.  Census,  1914,  p.  48. 

*Ibid.,  p.  25. 

»S.  H.  C,  30th  A.  R.,  p.  282. 

*Rosanoff,  A.  J.,  "Some  Neglected  Phases  of  Immigration,"  Amer. 
Jo.  of  Ins.,  July,  1915,  p.  47;  points  out  the  apparent  shortcomings  in 
computing  percentages  without  considering  age  distribution. 


'■39] 


INSANITY  AS  A  COMMUNITY  PROBLEM 
Table  ii.    Nativity 


Arabia 

Austria- Hungary 

Belgium   

England 

France 

Germany 

Greece  

Palestine 

Persia 

Roumania 

Russia 

Spain    

Switzerland 

Turkey 


Total 


Native  born 


Totals 


Male. 


127 

II 
I 

20 

I 

24 

284 

I 

I 

4 


476 
197 


673 


Female. 


"5 
I 
6 
I 

15 
I 

I 


344 
no 


454 


97 


Total. 


I 

242 
2 

17 
2 

35 
I 
I 
I 

38 

472 
I 
I 
6 


820 


307 


1,127 


All  unusually  large  number  of  the  immigrants,  especially  the 
Jews,  settle  in  the  urban  districts,  more  often  in  the  larger 
cities.  It  is  an  established  fact  that  an  urban  environment 
brings  to  the  surface  neuropathic  tendencies  of  a  community 
far  more  fully  than  a  rural  environment.  Considering  this 
factor  together  with  the  difference  in  age  distribution,  and 
making  some  allowance  for  the  heavy  stress  entailed  in  the 
migration  and  in  the  subsequent  process  of  adjustment  to 
new  conditions  and  more  exacting  standards  of  living,  there 
is  found  to  be  but  little  difference,  if  any,  between  the  native 
and  foreign-bom  parts  of  the  population  in  the  incidence  of 
certified  insanity.' 

Table  11  indicates  that  820  or  y2.y  per  cent  of  the  total 


'  De  Fursac  and  Rosanoff,  p.  19. 


gS      SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [240 

Jewish  admissions  under  consideration  were  of  foreign 
birth,  and  307  or  27.3  per  cent  were  native  bom.  Russia 
contributed  more  than  half  of  the  foreign  bom,  284  males 
and  188  females,  a  total  of  472;  from  Austria-Hungary 
came  127  males  and  115  females,  a  total  of  242;  Roumania 
contributed  a  total  of  38,  Germany  35,  England  17,  Turkey 
6,  Belgium  2,  France  2,  and  i  each  from  Arabia,  Greece, 
Palestine,  Persia,  Spain  and  Switzerland.  The  figures  of 
admissions  to  the  psychopathic  wards  indicate  approxi- 
mately the  proportion  of  Jewish  immigration  from  the  vari- 
ous countries  during  recent  years,  especially  the  last  20  to  30 
years  prior  to  19 14.  In  view  of  what  has  been  said  on 
the  matter  of  age  distribution  among  immigrants  and  the 
fact  that  y2.y  per  cent  of  admissions  in  one  year  were 
foreign-bom,  any  seeming  disproportion  of  insanity  among 
Jews  in  the  United  States,  particularly  in  New  York, 
where  most  Jews  live,  must  be  discounted.^  The  further 
fact  that  nearly  all  Jewish  immigrants  settle  in  the  cities, 
especially  in  the  congested  sections  of  the  large  seaboard 
communities,  should  render  judgment  still  more  cautious. 
From  all  available  facts,  the  only  conclusion  that  can  be 
drawn  indicates  that  there  is  no  greater  proneness  toward 
mental  disease  in  the  foreign-bom  than  in  the  native  popula- 
tion and  that  the  excessive  proportion  of  hospital  admissions 
furnished  by  the  foreign-born  is  due  to  other  causes. 

IX.    AGE  DISTRIBUTION 

Table  12  indicates  the  age  distribution  of  the  patients  ad- 
mitted. In  interpreting  the  figures  it  should  be  remembered 
that  the  several  chnical  groups  differ  widely  with  respect  to 
age  distribution  on  admission.     The  senile  and  arterioscler- 

'  U.  S.  Census,  Population,  vol.  i,  p.  <S26,  gives  the  foreign-born 
population  in  New  York  City  in  1910  as  40.8  per  cent  of  the  total 
population ;  for  the  Borough  of  Manhattan,  47.9  per  cent. 


241] 


INSANITY  AS  A  COMMUNITY  PROBLEM 


99 


otic  cases  are  found  principally  in  the  advanced  age  groups ; 
the  alcoholic,  paretic  and  paranoiac  cases  occupy  the  middle- 
life  groups;  and  the  manic  depressive  (see  Table  6)  and 
dementia  praecox  (see  Table  8)  cases  are  most  prominent  in 
the  age  groups  from^  20  to  40  years.  ^ 

Table  12.    Age  Distribution 


Under  15  years 

»5-i9  

20-24  

25-29  

30-34  

35-39  

40-44  

45-49  

50-54  

55-59  

60-64  

65  and  over  . . 

Totals  . 


Male. 


120 
107 
72 
80 
63 
41 
29 
II 
18 
27 


673 


Female. 


9 
61 

85 
73 
66 

50 
21 

25 

24 

8 

7 
25 


454 


Total, 


16 

159 

201; 
180 

138 
130 

84 
66 

53 
19 
25 
52 


1,1:7 


For  the  country  as  a  whole  in  the  comparison  of  native  and 
foreign  born  insane  according  to  age  distribution,  the 
contrast  is  less  striking  in  individual  age  groups  than  it  is 
in  the  total  population.  For  all  ages  combined  the  ratio  is 
twice  as  large  as  it  is  for  the  native;  but  there  is  no  such  dis- 
proportion between  the  ratios  in  any  one  of  the  age  groups.^ 


X.    DEPORTATION  OF  IMMIGRANT  INSANE 

A  circumstance  which  may  have  some  influence  upon  the 
ratio  of  admissions  to  hospitals  for  the  insane  in  the  case 

'  The    same    distribution    of    clinical    groups    in    the    indicated    age- 
groups  is  general  for  the  entire  state.     (S.  H.  C,  30th  A.  R.,  p.  297.) 
'^Insane  and  Feebleminded  in  Institutions,  U.  S.  Census,  1914,  p.  26. 


lOO     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [242 

of  the  foreign  born  is  the  fact  that  under  the  present  im- 
migration laws  the  insane  among  immigrants  are  debarred 
from  entering  the  United  States,  or  if  insanity  develops 
within  five  years  after  entrance,  are  Hable  to  be  deported. 
Thus  it  might  be  said  that  as  regards  insanity,  the  foreign- 
born  remaining  in  the  United  States  are  to  a  certain  extent 
a  selected  class,  and  that  so  far  as  the  influence  of  this  one 
factor  goes,  there  should  be  less  insanity  among  them  than 
among  the  native  population.  The  Bureau  of  Deportation 
of  the  New  York  State  Hospital  Commission  brought  about 
the  deportation  of  the  following  numbers  of  aliens  :•  in  1914, 
825;  191 5,  490;  1916,  208:  1917,  52;  and  1918,  53.^  Had 
it  not  been  for  the  commencement  of  hostilities  in  Europe 
and  the  consequent  practical  impossibility  of  carrying  out 
deportation  proceedings  to  any  extent  after  July,  1914,  the 
last  year  would  probably  have  recorded  about  900  de- 
portations. Whether  the  larger  number  of  these  900  aliens 
w^as  insane  or  of  neuropathic  constitution,  the  fact  must 
remain  that  in  a  simple  environment,  such  as  they  had  come 
fn^ni  many,  if  not  the  majority,  would  have  continued  to 
live  normal  lives  and  never  have  become  inmates  of  hos- 
pitals for  the  insane. 

The  fact  that  the  artificial  and  stressing  environment  into 
which  they  are  thrown  in  our  large  cities,  whether  at  work 
or  at  home,  either  causes  or  stimulates  the  onset  of  mental 
disturbance,  should  entitle  the  foreign-bom  to  further  con- 
sideration than  is  often  granted  them.  Stricter  and  more 
stringent  examination  before  they  embark  and  at  the  port 
of  entry,^  with  a  lessened  zeal  in  deporting  those  who  be- 
come insane  while  occupied  in  industries  in  the  land  of 

^S.  H.  C.  30th  A.  R.  p.  77- 

*The  Evening  Post,  New  York,  editorial.  "A  Better  Immigration 
Service,"  Nov.  26,  1919. 


243] 


INSANITY  AS  A  COMMUNITY  PROBLEM 


lOl 


their  adoption,  might  be  a  saner  and  more  humane  policy 
to  follow/ 

XI.    YEARS  RESIDENT   IN    UNITED  STATES 

The  figures  indicating  the  distribution  of  the  patients  ac- 
cording to  the  years  in  the  United  States  (Table  13)  show 
very  clearly  the  influence  of  the  war  in  stopping  immigra- 
tion, for  there  were  only  32  patients  admitted  who  had  come 
to  this  country  within  four  years.  There  were  127  in  the 
country  from  four  to  six  years;  201  from  eleven  to  fifteen 
years ;  307  were  native  bom. 


Table  13.     Years  in  United  States 


Less  tfaan  i  year 

1-3 

4-6 

7-10-  

"-15 

Over  15 

Life 

Totals  .. 


Male. 


2 

18 

79 

99 

III 

167 

197 


673 


Female. 


2 
10 
48 

73 

90 

121 

no 


454 


Total. 


4 

28 

127 

172 

201 
288 

307 


1,127 


With  the  end  of  the  war,  a  new  wave  of  immigration  has 
begun,  and  efforts  should  be  redoubled  to  keep  out  those 
who  are  either  physically  or  mentally  ill,  or  who  are  liable, 
because  of  constitutional  weakness  or  inferiority,  to  break; 
down  under  the  stress  and  strain  involved  in  the  adjustment 
to  a  new  environment  and  more  exacting  occupations. 

XII.    NEW  IMMIGRATION  LAW  AND  INSANITY 

The  new  immigration  law  which  passed  both  houses  of 
Congress  over  the  President's  veto  and  became  effective  May 

*  Ward,  Robert  DeC,  "  The  Crisis  in  our  Immigration  Policy,"  The 
Institutional  Quarterly;  official  organ  of  the  Public  Charity  Service 
of  Illinois,  vol.  iv,  no.  ii,  1913,  p.  14. 


102     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [244 

I,  1 91 7,  contains  many  provisions  that  will  aid  New  York 
State  in  its  efforts  to  free  itself  from  the  burden  of  the 
alien  insane. 

Section  3  provides  for  the  exclusion  of  persons  who  have 
had  one  or  more  attacks  of  insanity  at  any  time  previously, 
instead  of  "  persons  who  have  been  insane  within  five  years 
previous;"  and  adds  to  the  excluded  classes  persons  of 
constitutional  psychopathic  inferiority  and  persons  with 
chronic  alcoholism. 

The  law  further  imposes  a  fine  upon  transportation  com- 
panies of  $200  for  bringing  in  cases  of  insanity,  constitu- 
tional psychopathic  inferiority  and  chronic  alcoholism.  If 
"  such  mental  or  physical  defect  might  have  been  detected  by 
means  of  a  competent  medical  examination,''  at  the  time  of 
embarkation,  an  additional  fine  of  $25  is  imposed. 

Section  11 -a  details  "inspectors  and  matrons  of  the 
United  States  Immigration  Service  for  duty  on  vessels 
carrying  immigrant  or  emigrant  passengers  between  foreign 
ports  and  ports  of  the  United  States."  The  object  of  this 
is  to  afiford  more  thorough  observation  and  examination  of 
aliens,  not  only  for  the  purpose  of  detecting  diseases  and 
mental  and  physical  defects  but  to  lighten  the  work  of  the 
medical  inspectors  at  the  port  of  entry. 

The  new  law  further  provides  that  all  aliens  shall  be  ex- 
amined by  not  less  than  two  medical  officers  and  two  in- 
spectors. This  new  method  in  a  short  while  resulted  in  the 
rejection  for  mental  defects  of  9.27  per  cent  of  the  im- 
migrants, whereas  formerly  only  2.29  per  cent  were  thus 
rejected. 

Furthermore,  the  new  act  authorizes  the  deportation  of 
"any  alien  who,  within  five  years  after  entry,  becomes  a 
public  charge  from  causes  not  affirmatively  showii  to 
have  arisen  subsequent  to  landing."  The  time  limit  for 
deportation  has   been   changed   from   3    to   5    years   and 


245]  INSANITY  AS  A  COMMUNITY  PROBLEM  103 

made  retroactive/  Through  the  enforcement  of  these 
measures  it  is  expected  that  a  larger  proportion  of  mentally 
sick  and  defective  persons  will  be  excluded  than  has  hereto- 
fore been  the  case.  The  test  of  the  efficacy  of  the  machinery 
to  be  provided  will  come  during  the  first  few  years  follow- 
ing the  resumption  of  the  normal  flow  of  immigrants. 

XIII.    DISPOSITION    OF    PATIENTS 

The  best,  and  in  most  of  the  states  the  only  organized 
agency  for  dealing  medically  with  mental  disorders  is  the 
state  hospital.  Outside  of  the  walls  of  such  institutions  the 
field  of  psychiatry  is  practically  a  neglected  waste."  The 
result  of  this  is  that  a  striking  contrast  prevails  between 
intra-hospital  and  extra-hospital  knowledge  and  methods. 
The  lack  of  knowledge  of  the  hospitals  and  their  work  is 
very  pronounced  among  the  general  public.  As  Table  14 
indicates,  of  the  total  admissions  numbering  1,127  patients, 
790  or  70.9  per  cent  were  committed  toi  state  hospitals. 
In  nearly  every  case  in  which  relatives  were  asked  to  sign 
commitment  papers,  with  occasional  exceptions  when  read- 
mitted patients  were  involved,  the  question  of  the  kind  of 
institution  the  patient  was  being  sent  to,  the  probable  dura- 
tion of  his  stay  there,  the  nature  of  the  treatment,  etc.,  had 
to  be  fully  explained  before  commitment  papers  were  signed. 
The  failure  to  be  fairly  well  informed  in  such  matters  is 
due  to  many  reasons  and  will  be  considered  in  another  con- 
nection. 

The  several  private  institutions  listed,  namely,  Rivercrest, 
Amityville,  Dr.  McFarland's,  Belle  Meade,  Spring  Hill, 
Green's  Farms,  and  Dr.  Combe's,  received  in  all  24  male 
and  14  female  patients,  a  total  of  38  or  3.3  per  cent  of  the 

'  S.  H.  C,  29th  A.  R.,  pp.  63-66. 

-Russell,  VVm.  L.,  "  What  the  State  Hospitals  can  do  in  Mental 
Hygiene,"  Mental  Hygiene,  Jan.,  1917,  pp.  88-89. 


I04     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [246 
Table  14.    Disposition  of  Patients 


Male. 

Female, 

Total. 

Manhattan  S   H 

252 

184 

4 

»7 

4 
4 

6 

9 

26 

10 

138 

13 

2 

201 

«47 

2 
8 

1 

* 
I 

'3 
I 

2 

I 
2 

2 
I 

5 
70 

6 

453 
6 

Central  Islip  S.  H 

Kings  Park  S.  H 

25 

Dr.  McFarland's  Sanit 

Belle  Meade  Sanit 

I 

Green's  Farm  Sanit 

Dr.  Combe's  Sanit 

Randall's  Is 

I 

3 

S 

Inwood  House 

Dept.  of  Pub.  Char 

I 
g 

Trans,  to  other  Wards 

II 

27 

208 

Died 

*9 

Totals 

673 

454 

1,127 

total  admissions,  or  4.5  per  cent  of  the  patients  admitted 
to  state  institutions.  The  reason  so  few  were  committed  tO' 
private  sanatoria  was  because  of  the  economic  condition  of 
the  patients  and  their  next  of  kin  or  friends ;  in  fact,  many 
of  those  sent  to  these  institutions  were  withdrawn  within 
a  few  weeks  due  to  lack  of  funds  and  transferred  to  state 
hospitals. 

The  New  York  City  Children's  Hospital  and  School,  an 
institution  for  mental  defectives,  received  five  patients:  2 
morons,  i  low-grade  moron,  2  imbeciles.  These  patients 
had  became  troublesome  at  home  or  were  found  on  the 
streets  by  the  police  and  brought  to  the  psychopathic  wards. 

Waverly  House,  a  temporary  shelter  for  delinquent  girls 
over   16  years   of  age,  sent  one  young  woman  who  had 


247]  INSANITY  AS  A  COMMUNITY  PROBLEM  105 

attempted  suicide,  for  examination  and  disposition.  She 
was  diagnosed  as  being  constitutionally  inferior  and  re- 
turned to  the  shelter.  One  boy  came  from  the  House  of 
Refuge,  a  custodial  institution  for  delinquents;  he  was 
found  to  be  constitutionally  inferior,  and  was  returned  to 
the  institution. 

InwcKxi  House,  a  custodial  institution  and  reformatory 
home  for  wayward  girls  and  women,  sent  one  girl  for  ex- 
amination because  of  what  were  thought  to  be  symptoms  of 
mental  disorder.  Examination  showed  that  she  was  a 
mental  defective  (moron)  afflicted  with  tertiary  syphilis; 
she  was  returned  to  the  institution  whence  she  came. 

The  2  boys  returned  to  the  truant  school  from  which  they 
had  been  sent  for  mental  examination  and  observation  were 
found  to  be  morons. 

The  patients  sent  to  the  Department  of  Public  Charities, 
(now  the  Department  of  Public  Welfare)  were  transferred 
to  the  City  Hospital,  Blackwell's  Island.  Of  the  2  females, 
I  was  an  epileptic,  the  other  a  case  of  senility ;  among  the  6 
males,  there  were  2  cases  of  arteriosclerosis,  i  chronic  alco- 
holic, I  chronic  nephritic,  i  of  cerebral  syphilis,  i  of  cancer 
of  the  tongue.  All  of  these  showed  some  slight  mental  dis- 
turbance besides  being  chronic  somatic  cases ;  they  were  not 
however,  considered  suitable  patients  for  a  state  hospital- 
Such  patients  as  were  found  to  need  further  hospital 
treatment  but  were  not  suitable  cases  for  the  psychopathic 
wards  were  transferred  to  other  wards  of  the  hospital. 
This  happened  in  the  case  of  1 1  patients,  nearly  all  of  whom 
were  either  alcoholics  or  drug  addicts,  or  cases  of  attempted 
suicide  detained  as  prisoners  under  Article  202,  Section 
2,303  of  the  Penal  Law  which  provided  that  "  every  person 
guilty  of  attempting  suicide  is  guilty  of  a  felony,  punishable 
by  imprisonment  in  a  state  prison  not  exceeding  two  years, 
or  by  a  fine  not  exceeding  one  thousand  dollars,  or  both." 


Io6     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [248 

Upon  being  returned  to  the  magistrate's  courts  after  re- 
covery, the  patients  who  attempted  suicide  were  as  a  rule 
lectured  by  the  magistrate  and  discharged  from  custody. 
This  section  of  the  Penal  Law,  making  an  attempt  at  suicide 
a  crime  punishable  by  fine  or  imprisonment  or  both,  was  re- 
pealed May  5,  1919,^  and  there  is  no  longer  any  legal  re- 
striction affecting  suicidal  attempts. 

XIV.    MENTAL  EXAMINATION   OF   PRISONERS 

Judges  in  the  courts  of  the  city  sent  2y  persons  to  the 
psychopathic  wards  for  mental  examination,  after  having 
first  remanded  them  to  the  City  Prison  (The  Tombs)  to 
await  indictment  and  trial ;  in  several  instances  lawyers  re- 
quested that  their  clients  be  sent  to  the  hospital  for  mental 
examination  in  order  to  determine  the  mental  responsibility 
of  tlie  prisoners,  often  hoping  thereby  to  obtain  either  a 
reduced  or  suspended  sentence,  or  to  have  the  prisoners 
paroled,  if  guilty  of  the  indictment.  The  following  table 
indicates  the  diagnoses  in  these  cases : 

Table  15.    Diagnosis  of  Prisoners 


Female. 


Constitutionally  Inlerior, 
Mental  Def.  (Moron) . . . 
Mental  Def.  (Imbecile)  • 
*  Dementia  Praecox  .... 

Psychoneurosis 

Chronic  Heroin  User  . . . 
Manic  Depressive,  Mixed 

Chorea 

Not  Insane 

Totals 


*  Two  were  former  patients  in  state  hospitals;  one  came  from  an- 
other state. 
^  Laws  of  1919,  chap.  414. 


249]  INSANITY  AS  A  COMMUNITY  PROBLEM  107 

Better  and  more  adequate  facilities  for  the  mental  exam- 
ination of  adult  prisoners,  as  is  already  provided  in  the 
children's  courts/  would  help  guide  magistrates  and  judges 
in  intelligently  disposing  of  the  cases  of  those  appearing 
before  them  in  whom  some  mental  abnormality  exists.^ 
There  were  in  addition  10  males  and  5  females  sent  for 
examination  directly  from  the  courts  and  upon  examination 
4  were  found  to  be  mental  defectives  (morons) ;  2  con- 
stitutionally inferior ;  i  psychoneurotic ;  4  who  were  cases  of 
attempted  suicide,  were  diagnosed  as  not  insane;  and  3 
were  found  to  be  of  normal  mental  make-up. 

XV.    MENTAL  DEFICIENCY  LAW 

To  meet  the  problem  of  providing  proper  custodial  care 
for  mental  defectives  and  of  otherwise  looking  after  the  wel- 
fare both  of  the  community  and  of  the  mental  defectives 
therein,  Chapter  633,  Laws  of  19 19,  was  passed  and  became 
a  law  on  May  14,  191 9.  This  act,  known  as  the  Mental 
Deficiency  Law,  provides  for  the  appointment  of  a  Com- 
mission of  Mental  Defectives,  of  which  Dr.  Pearce  Bailey 
has  since  been  appointed  chairman.  Among  other  things, 
provision  is  made  in  Section  24-a  for  the  diagnosis  and 
treatment  for  mentally  defective  persons  before  or  after 
trial.     This  section  of  the  law  reads  as  follows: 

Any  person  alleged  to  be  mentally  defective  .  .  .  arraigned 
on  a  criminal  charge  may  be  committed  before  or  after  trial 
or  conviction  to  a  hospital  or  other  suitable  place  selected  by 
the  state  commission  for  mental  defectives  .  .  .  for  a  period 
not  to  exceed  ten  days,  for  examination  as  to  his  mental  and 
physical  condition,  by  any  court  or  magistrate.  ...  If  the 
examination  discloses  that  the  alleged  mentally  defective  person 

'  Baldwin  and  Flexner,  op.  cit.,  p.  127. 

*  Vide  studies  of  prisoners  in  psychiatric  clinic  of  Sing  Sing,  by 
Bernard  Glueck,  Mental  Hygiene,  Jan.,  1918,  pp.  85-151 ;  Mental  Hygiene, 
April,  1918,  pp.  177-218. 


Io8     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [250 

is  of  such  a  nature  as  to  require  his  supervision,  control  and 
care  for  his  own  welfare  or  for  his  own  welfare  and  the  welfare 
of  others  or  for  the  welfare  of  the  community,  the  judge  or 
justice  shall  issue  an  order  for  his  commitment  to  one  of  the 
state  institutions  for  mental  defectives. 

The  Commission  has  designated  Bellevue  Hospital,  Man- 
hattan, and  Kings  Coimty  and  the  Cumberland  Street 
Hospitals,  Brooklyn,  as  the  institutions  in  New  York  City 
to  which  such  cases  shall  be  sent. 

XVI.    DISCHARGES  FROM   PSYCHOPATHIC  WARDS 

The  crowded  conditions  in  the  psychopathic  wards  as 
well  as  in  the  state  hospitals  are  sufficient  to  induce 
physicians  in  the  psychopathic  wards  to  permit  relatives  who 
refuse  to  sign  papers  for  the  commitment  of  mild  and 
borderline  cases  to  take  such  patients  home  after  contracting 
to  be  responsible  for  any  damage  or  injury  they  may  cause. 
This  has  led  to  the  discharge  of  a  ntmiber  of  such  patients 
to  the  custody  of  friends  and  relatives.  Almost  invariably, 
with  the  possible  exceptions  where  patients  are  taken  out 
of  the  city  or  are  sent  to  private  sanatoria,  the  relatives  of 
such  discharged  patients  return  within  a  short  time  stating 
that  due  to  their  inability  properly  to  care  and  provide  for 
the  patients  taken  home  against  the  advice  of  the  doctors, 
they  are  prepared  to  have  such  patients  committed  to  state 
hospitals.  Table  16  lists  the  discharges  according  to 
diagnosis;  there  were  138  males  and  70  females,  a  total  of 
208,  equivalent  to  18.4  per  cent  of  the  total  number  of 
admissions. 

It  is  almost  needless  to  remark  that  were  there  in  New 
York  an  institution  to  which  a  number  of  the  above  pat- 
ients might  have  been  sent,  as  to  a  psychopathic  hospital, 
relatives  would  consider  a  stay  in  sucli  an  institution  ad- 


251]  INSANITY  AS  A  COMMUNITY  PROBLEM  109 

visable  and  would  not  have  taken  the  mentally  ailing  back 
to  their  poor  and  uninviting  homes,  only  to  have  a  more 

Table  16.    Diagnosis  of  Discharges 


Male. 

Female, 

Totals. 

8 

4 

4 

13 

2 

I 

12 
I 

19 
27 

6 
13 

3 
I 
I 

7 
I 

5 
5 
4 

I 
2 

2 
8 
5 
>S 
9 
I 

3 

7 
5 
4 
4 
2 

2 
70 

9 
4 
6 

13 
z 

Organic  Nervous  Disease  .... 

I 

Cerebral  Hemorrhage 

I 

14 
9 
5 

36 

Infection  Exhaustion  Psych. - 

Paranoid  Condition 

3 

s 

Constitutionally  Inferior 

6 
1 1 

Depression  Undifferentiated. . 

Transitory  Confusion 

Unclassified .... 

5 
7 
5 
6 

Totals 

'38 

208 

serious  relapse  within  a  short  time,  with  commitment  to  a 
state  hospital  the  only  alternative. 

XVII.    DEATHS  IN  PSYCHOPATHIC  WARDS 

Nineteen  patients  died  in  tlie  psychopathic  wards,  13 
males  and  6  females.  A  number  of  these  had  been  trans- 
ferred from  other  wards  in  the  hospital  in  which  they  had 
become  unmanageable  and  a  disturbance  to  the  other 
patients  in  the  wards  with  them. 

Table  1 7  indicates  the  cause  of  death : 


1 10     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE      [252 
Table  17.    Diagnosis  of  Deaths 


Male. 

4 

I 
2 
2 
2 
I 
I 

Female. 

Totals. 

3 

7 
2 
2 

Infection  Exhaustion 

Pulmonary  Tuberculosis 

2 
2 

Tubercular  Meningitis 

Pleurisy   

Blood  Poisoning 

Cerebral  Spinal  Lues 

I 
I 
I 
I 

Totals 

>3 

6 

19 

XVIII.    SUMMARY 

In  this  chapter  the  aim  has  been  not  merely  to  present 
the  statistics  deaHng  with  the  psychopathic  ward  admissions, 
but  also  thereby  to  indicate  the  many  needs  that  must  be 
met  ere  a  more  effective  policy  in  dealing  with  mental  cases 
in  New  York  City  and  State  can  be  evolved.  The  problem 
is  not  a  simple  one  nor  easy  of  solution,  as  the  mere  dif- 
ficulty in  obtaining  or  agreeing  upon  an  adequate  and  satis- 
factory definition  as  to  what  constitutes  mental  alienation  or 
insanity  has  shown.  Psychiatry  is  of  recent  origin  and 
the  human  ills  it  aims  to  help  and  to  cure  are  manifold. 
Still,  with  the  information  already  at  hand,  and  the  augmen- 
tation thereof  that  we  may  look  forward  to,  it  is  not  too 
much  to  ask  nor  yet  to  expect  that  those  who  are  in  the 
service  of  the  state  in  this  particular  field  shall  assist  the 
community  not  only  to  return  those  of  unsound  mind  to  a 
condition  of  sanity,  but  shall  also  take  the  lead  in  educating 
the  public  to  a  fuller  understanding  of  the  causes,  preventa- 
tives and  cures  of  insanity,  as  far  as  available  scientific 
knowledge  will  permit. 


CHAPTER  III 
Results  of  State  Hospital  Care  and  Treatment 

i.  need  and  provisions  for  scientific  study  of  insanity 

Scientific  observation  and  experience  form  the  firm  founda- 
tion upon  which  the  whole  question  of  the  care  of  the  insane  is 
based.  Every  step  forward — and  many  steps  backward — in 
the  care  of  the  insane  are  more  or  less  closely  related  with  the 
medical  conceptions  regarding  the  existence  and  the  causes  of 
insanity.  It  has  become  more  and  more  the  duty  of  the  state 
to  foster  scientific  investigations  in  the  hospitals  for  the  insane. 
In  this  respect  psychiatry  has  long  enough  been  treated  as  a 
stepchild.  Although  our  old  asylum  physicians  afford  brilliant 
examples  of  what  can  be  accomplished  with  very  inadequate 
means  in  the  attainment  of  high  scientific  ideals,  the  state  has 
only  recently  recognized  that  a  healthful  progress  in  the  care  of 
the  insane  is  not  possible  without  a  continuous  development 
of  scientific  work.^ 

Thus  wrote  Kraepelin  of  the  development  of  experimen- 
tal and  laboratory  work  and  research  in  his  native  country, 
and  his  words  may  very  properly  be  applied  to  conditions  as 
they  have  existed  and  still  exist  with  but  few  exceptions, 
in  the  United  States.  To  meet  just  this  problem  as  well  as 
to  centralize  research  aiming  to  achieve  a  better  understand- 
ing and  knowledge  of  the  etiology  of  the  various  forms  of 
insanity,  and  likewise  to  discover  cures  therefor,  the  State 
Hospital  Commission  (at  that  time  the  State  Commission  in 

'Quoted  by  Drewry,  Wm.  F.,  "  Care  and  Condition  of  the  Insane  in 
Virginia,"  Nafl.  Conf.  of  Char,  and  Con.  Report,  igo8,  p.  307. 

253]  111 


112     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [254 

Lunacy)  in  1896  organized  the  Pathological  Institute,  now 
known  as  the  Psycliiatric  Institute.  This  agency  through 
its  medical  officers  acts  as  the  standardizing  factor  in  the 
state  hospital  system,  instructing  thq  physicians  in  the 
several  hospitals  in  the  application  of  a  standard  classifica- 
tion of  the  psychoses,  in  the  organization  of  the  clinical  or 
out-patient  service  as  well  as  of  the  staff  meetings,  in  the 
work  of  the  pathological  laboratory,  and  also  in  the  compila- 
tion of  the  medical  statistics.^  Though  all  of  this  work  is 
important,  the  institute  is  greatly  hampered  because  of  the 
lack  of  a  sufficiently  large  appropriation  with  which  to  carry 
on  necessary  and  extensive  investigations,  the  allotment  tO' 
this  division  of  the  state  hospital  system  for  the  year  19 18 
having  been  only  about  $28,000,-  a  smaller  amount  than 
was  appropriated  for  this  work  twenty  years  ago.* 

One  of  the  prime  necessities  for  scientific  research  in  the 
field  of  mental  diseases  is  a  sufficiently  large  and  varied 
number  of  patients,  presenting  many  forms  of  mental 
alienation,  together  with  a  wide  range  in  social  status,  en- 
vironment, occupation,  nationality,  etc.  In  the  New  York 
State  Hospitals  for  the  insane  there  were  under  treatment 
on  June  30,  191 8,  33,868  patients  supported  wholly  by  the 
state,  3,303  reimbursing  patients,  and  181  private  cases, 
making  a  total  of  37,352.*  probably  the  largest  number  of 
patients  under  institutional  care  in  any  state  in  the  country. 
Since  the  thirteen  civil  state  hospitals  are  located  in  different 

'S.  H.  C,  30th  A.  R..  1918,  p.  144- 

^  Ibid.,  p.  267. 

"Ibid.,  p.  267.  The  largest  amount  appropriated  was  in  1899,  when 
136,000  was  granted;  the  largest  amount  spent  was  in  1897,  $40,058.28. 
Since  then  the  appropriations  as  well  as  the  expenditures  have  been 
between  $20,000  and  $30,000  per  annum,  except  in  1900,  when  $35,155.53 
was  spent,  though  only  $20,000  was  originally  appropriated. 

♦  S.  H.  C.  30th  A.  R..  p.  327- 


255]        -ST^TE  HOSPITAL  CARE  AND  TREATMENT  113 

parts  of  the  state,  each  receiving  patients  from  the  district  in 
which  it  is  situated,  there  is  sufficient  laboratory  material 
upon  which  to  draw  for  scientific  purposes.  Insofar  as 
the  factor  of  different  nationaHties  represented  among  the 
patients  is  concerned,  it  might  be  interesting  tO'  note  that 
there  were  almost  forty  countries  which  contributed  to  the 
insane  population  of  the  New  York  hospitals,  though  the 
native-born  in  these  hospitals  for  the  year  ending  June  30, 
1918  were  over  half  of  the  total,  namely  55.5  per  cent.'' 
Considering  this  wealth  of  clinical  and  pathological  material, 
as  well  as  the  large  number  of  specialists  engaged  in  the 
care  and  treatment  of  these  37,352  patients,  it  would  seem 
that  much  information  of  a  helpful  and  serviceable  nature 
in  effecting  recoveries  of  insane  persons  should  be  forth- 
coming from  those  associated  in  the  psychiatric,  psychologic 
and  pathologic  work  in  the  New  York  State  Hospitals. 

These  institutions,  rated  among  the  best  of  their  kind  in 
America,  have  not,  however,  witnessed  the  issuance  from 
within  their  walls  of  contributions  of  unusual  worth  in  the 
field  of  psychiatry,  nor  in  the  other  branches,  namely, 
psychology  or  pathology.  This  failure  has  not  been  alto- 
gether, if  at  all,  the  fault  of  the  psychiatrists  and  others  who 
should  rightfully  have  been  expected  to-  carry  on  researches 
of  particular  scientific  importance.  It  has  rather  been  due, 
as  pointed  out  above,  to  the  failure  on  the  part  of  the  state 
to  appropriate  sufficient  money  for  the  work  of  the  psychia- 
tric institute,  and  furthermore,  to  still  another  factor — the 
overcrowding  which  has  existed  in  the  state  hospitals  for 
many  years,  with  the  concomitant  shortage  of  physicians, 
nurses,  laboratory  technicians,  attendants,  etc.  It  is  to  thisi 
latter  problem  in  particular  that  practically  all  hospital 
superintendents  have  had  to  devote  much  of  their  time,  for 

1  S.  H.  C,  30th  A.  R.,  p.  292. 


114 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[256 


wkh  little  extension  of  building  operations  during  the  past 
few  years  and  with  an  ever  increasing  population  and  a  pro- 
portionate increase  in  the  number  of  cases  of  insanity  com- 
mitted to  the  already  overcrowded  state  hospitals,  the  prob- 
lem has  become  more  aggravated  each  year.^ 


II.    OVERCROWDING 


The  following  table  indicates  the  overcrowding  of  the 
state  hospitals  as  conditions  existed  on  June  30,  1918.'- 

Table  18.    Overcrowding  in  the  State  Hospitals 


Population 

June  30,  191 8, 

Excluding 

Paroles. 

Rated 
Capacity. 

Overcrowding. 

Hospitals. 

No. 

Per  cent. 

2,701 
884 
2,202 
5.040 
1,281 
3,428 
4,479 
5,327 
2,181 

1,541 

2,285 
1,687 
2,426 

2,400 

637 
1,700 
4,100 

950 
2,850 

3,500 
4,250 
1,800 
1,260 
1,950 
1,400 
2,200 

301 

247 
502 
940 
331 
578 
979 
1,077 

381 
281 

335 
287 
226 

12.5 
38.8 

29-5 
22.9 

34-8 
20.3 
28.0 

Buffalo 

Central  Islip 

Hudson  River 

Kings  Park 

25-3 
21.2 

22.3 
17.2 
20.5 
10.3 

St.  Lawrence 

Utica 

Willard 

Totals 

35,462 

28,997 

6,465 

22.3 

There  appears  but  little  possibility  of  lessening  the  over- 

^  Page,  Charles  Whitney,  The  Care  of  the  Insane  and  Hospital  Man- 
agement, 1912;  presents  a  discussion  of  the  method  to  be  followed  in 
choosing  a  superintendent,  his  qualifications,  duties,  his  official  relation 
to  officers  and  employees,  etc. 

'  S.  H.  C,  30th  A.  R.,  p.  235.  Also  Hastings,  George  A.,  "  Some 
Essentials  of  a  State  Program  for  Mental  Hygiene,"  State  Char.  Aid 
Assn.  Publuation,  no.  146,  pp.  11-14. 


257]        ^'^^'^E  HOSPITAL  CARE  AND  TREATMENT  115 

crowded  conditions  before  plans  thus  far  developed  by  the 
Hospital  Development  Commission  are  carried  oiit.'^ 
Among  the  more  important  recommendations  of  the  com- 
mission are :  A  new  state  hospital  at  Creedmoor ;  enlarging, 
the  hospitals  in  and  near  New  York  City;  securing  a  site 
for  a  new  hospital  in  the  metropolitan  district  in  place  of 
the  abandoned  Mohansic  institution;  the  establishment  of 
a  psychopathic  hospital  in  New  York  City;  completion  of 
a  state  hospital  at  Marcy  near  Utica ;  a  more  orderly  method 
of  making  appropriations;  better  planning  of  institutions, 
and  more  preventive  and  research  work." 

III.    EXTENSION  OF  OBSERVATION  PERIOD 

Still  another  factor  in  the  overcrowding  of  the  state  hos- 
pitals has  been  the  shortness  of  the  detention  period  in  the 
observation  wards  of  the  municipal  institutions.  Patientsi 
brought  to  the  psychopathic  wards  of  Bellevue  and  other 
hospitals  are  not  kept  there  for  a  sufficient  length  of  time  to^ 
permit  those  suffering  from  slight  attacks  tO'  recover  prior 
to  their  commitment  to  a  state  hospital.^  The  reasons  for 
this  are  two- fold;  in  the  first  place,  the  officers  of  the  obser- 
vation or  psychopathic  wards,  particularly  of  the  largest 
among  them,  Bellevue,  to  which  came  the  cases  considered 
in  this  work,  have  for  a  number  of  years  been  facing  the 
same  difficulty  as  the  state  hospitals,  to  wit,  lack  of  suffi- 
cient accommodations.  Were  it  possible  to  detain  a  number 
of  the  so-called  hopeful  cases  for  ten  days  or  more  until 
they  had  recovered  from  the  attack  which  caused  them  to  be 

1  Survey,  Jan.  26,  1918,  p.  467,  "  Crowding  in  the  Insane  Hospitals." 

» S.  H.  C,  30th  A.  R.,  pp.  225-22^. 

'Mason,  Frank  H.,  "  Modern  Hospital  for  the  Insane,"  Daily  Consular 
Reports,  Dept.  of  Commerce  and  Labor,  no.  2264,  May  22,  1905;  gives 
an  illustrated  description  of  the  reception  hospital  erected  by  the  city 
of  Munich,  Germany,  for  the  temporary  care  and  treatment  of  incipient 
cases.    Dr.  Emil  Kraepelin  was  appointed  director  of  this  hospital. 


Il6     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [258 

brought  to  the  psychopathic  ward,  in  the  majority  of  such 
cases  commitment  to  a  state  hospital  might  have  been 
avoided.  It  is  quite  apparent  that  such  a  plan  would  in 
practice  amount  to  a  working  out  of  the  psychopathic 
hospital  idea  within  the  limited  confines  of  wards  in  muni- 
cipal hospitals.  xAjiy  means  employed  tO'  decrease  the 
crowded  conditions  of  our  state  hospitals  and  at  the  same 
time  aid  in  the  early  recovery  of  a  number  of  patients  would 
be  welcomed  by  all  interested  in  the  proper  care  and  treat- 
ment of  the  insane.  The  second  reason  for  the  short  dura- 
tion of  the  observation  period  lies  in  that  provision  of  the 
Insanity  Law  which  reads  as  follows :  "  In  no  case  shall 
any  insane  person  be  confined  in  any  other  place  than  a 
state  hospital  or  duly  licensed  institution  for  the  insane,  for 
a  period  longer  than  ten  days."'  This  of  course  makes  it 
impossible  for  any  municipal  hospital  maintaining  a  psycho- 
pathic service  to  detain  an  insane  or  alleged  insatie  person 
longer  than  the  period  of  time  prescribed  in  the  law,  though 
an  extension  of  this  period,  if  limited  to  cases  indicated, 
would  undoubtedly  result  in  much  benefit. 

Table  19  indicates  that  47,  or  about  6  per  cent  of  the 
patients  were  transferred  to  state  hospitals  within  24 
hours  after  their  arrival  in  Bellevue  Hospital.  It  should  be 
pointed  out,  however,  that  most  of  these  were  cases  that 
were  out  on  parole  from  one  of  the  state  hospitals  and  had 
been  brought  to  the  psychopathic  wards  of  Bellevue  Hos- 
pital for  transfer  to  the  institution  from  which  they  had 
been  paroled.  Among  the  others  were  a  number  whose 
parole  period  had  expired  and  who  had  suffered  a  recurrent 
attack,  necessitating  their  re-commitment  to  the  state  hos- 
pital, usually  to  the  one  in  which  they  had  been  previously 
confined.  There  were  172  who  were  transferred  within 
two  days,  192  in  three  days,  129  in  four  days,  giving  a  total 

*  Oiap.  27  of  the  Consolidated  'Laws,  "  The  Insanity  Law,"  sec.  87. 


259] 


STATE  HOSPITAL  CARE  AND  TREATMENT 


117 


Table  19.    Number  of  Days  Spent  in  Psychopathic  Wards  of 
Bellevue  Hospital  Prior  to  Commitment  to  State  Hospital 


No.  of  Days. 


I 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Over  10 

Totals 


Manhattan. 


<u 

rt 

E 

s 

U^ 

8 

10 

48 

39 

56 

55 

43 

35 

29 

25 

22 

8 

13 

8 

II 

8 

4 

2 

12 

6 

6 

5 

252 

201 

Central  Is. 


20 
38 
41 
27 
20 

15 
6 
6 

5 
4 
2 


184 


5 

47 

39 

23 

9 

8 

5 
4 
I 

4 
2 


147 


Kings  Park.  1  Totals. 


13    O 
rt   g 


47 

172 

192 

129 

83 

53 

32 

29 

12 

26 

J5 


790 


of  540  or  68.3  ]>er  cent  transferred  within  four  days  from 
the  time  of  admission ;  83  were  detained  five  days,  making 
the  percentage  78.8  per  cent  of  the  total  kept  in  the  psycho- 
pathic wards  less  than  one-half  the  maximum  time  allowed 
by  law.  Most  of  the  1 5  who  were  kept  in  the  psychopathic 
wards  over  ten  days  were  remanded  to  the  hospital  by  some 
court  for  observation  and  examination,  and  the  ensuing 
complications  resulted  in  their  detention  one  or  more  days 
beyond  the  ten-day  period;  the  few  remaining  cases  could 
not  be  transferred  to  a  state  hospital  within  ten  days  be- 
cause of  their  mental  or  physical  condition,  or  both. 

Dr.  Henry  Maudsley  was  among  the  first  to  propose  the 
erection  of  an  observation  hospital  for  the  treatment  of  in- 
cipient mental  cases  in  London.  The  purposes  of  this  hos- 
pital were  to  be  largely  those  assigned  to  psychopathic  hos- 
pitals at  the  present  time.     In  smaller  communities,  how- 


Il8     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [260 

ever,  where  institutions  of  large  size  are  unnecessary,  psy- 
chopathic wards  in  the  local  general  hospitals  would  often 
be  the  means  of  preventing  insanity  and  accomplishing  the 
early  recovery  of  incipient  cases,  provided,  of  course,  that 
the  law  was  changed  to  allow  a  longer  detention  period  than 
is  at  present  prescribed. 

Among  the  states  making  specific  mention  in  their  laws  of 
the  length  of  time  patients  may  be  kept  in  observation  or 
psychopathic  wards,  California  provides  that  the  board  of 
supervisors  of  each  city  or  county  must  maintain  a  room  or 
rooms  suitable  for  the  detention,  care  and  treatment  of 
alleged  insane  persons,  for  a  period  of  not  more  than  twenty 
days/  The  District  of  Columbia  permits  the  detention  of 
such  persons  in  the  government  hospital  for  the  insane  or 
in  any  other  hospital  for  a  period  not  exceeding  thirty  days." 
Michigan  allows  for  the  detention  in  au}^  hospital,  home  or 
retreat  for  not  more  than  thirty  days,  except  by  special 
order  of  the  court. ^  In  the  State  of  Pennsylvania,  persons 
suffering  from  mental  disorders  may  be  committed  for  not 
more  than  thirty  days  to  the  psychopathic  wards  of  hospitals 
for  observation  and  treatment  in  the  same  manner  as  per- 
sons are  committed  to  hospitals  for  the  insane ;  but  persons 
admitted  to  these  wards  who  are  found  insane  must  be  re- 
gularly committed  and  removed  to  a  hospital  for  the  insane 
within  thirty  days.*  Some  of  the  more  important  advant- 
ages of  such  an  extended  period  over  the  ten  days  allowed 
by  law  in  New  York  State,  may  be  summed  up  as  follows :  ^ 

^Political  Code  of  California,  1905,  as  amended  by  Lazvs  of  1909. 
chap.  65,  sec.  2167. 

^Revised  Statutes  of  the  United  States,  Act  of  1904,  33  Stat.  316. 

3  Lazi's  of  1909,  pp.  16,  185. 

*Laws  of  191 1,  chap.  855,  sec.  2. 

^Briggs,  L.  Vernon,  "What  can  be  done  for  the  Prevention  of  In- 
sanity by  the  Treatment  of  Incipient  Cases  in  General  Hospitals,"  Amer. 
Jo.  of  Ins.,  April,  191 1,  p.  660. 


26l]        STATE  HOSPITAL  CARE  AND  TREATMENT  ng 

1.  The  incipient  case  would  have  the  advantage  of  im- 
mediate expert  care  by  members  of  the  hospital  staff  in  every 
branch  of  medicine  and  surgery. 

2.  He  would  have  the  advantage  of  a  large  hospital  nurs- 
ing staff  instead  of  attendants. 

3.  The  social  considerations  after  recovery  are  most  im- 
portant to  patients,  many  of  whom  would  thus  be  saved 
from  being  placed  in  an  insane  asylum, 

IV.    PRIVATE  SANATORIA  AND  HOSPITALS 

There  were  in  the  State  of  New  York  in  1918  a  total  of 
twenty-four  private  licensed  institutions*  with  a  licensed 
capacity  of  1,522  patients.  It  is  these  asylums  or  retreats 
which  serve  the  purpose  of  wards  in  general  hospitals,  but 
they  are  only  within  the  reach  of  those  whose  relatives  or 
friends  are  in  a  position  to  pay  from  $25.00  to  $100.00  or 
more  a  week.  Many  incipient  cases  are  discharged  as  re- 
covered or  improved  within  a  few  weeks  from  these  private 
institutions,  in  which  they  have  been  given  much  individual 
attention,  more  than  could  possibly  be  accorded  them  in  the 
state  hospitals.  This  does  not  of  course  mean  that  the  state 
hospitals  are  failing  to  effect  cures,  but  rather  that  for  in- 
cipient cases  some  institutions  other  than  state  hospitals  are 
at  present  prepared  to  render  better  service,  and  hence  in- 
crease the  ratio  of  recoveries,  because  of  proportionately 
larger  staffs,  better  equipment,  and  less  overcrowding. 
The  psychopathic  wards  or  "  Pavilion  F "  of  the  Albany 
Hospital  are  rendering  a  service  that  many  of  the  similar 
institutions  throughout  the  state  should  be  prepared  and 
equipped  to  give. '  This  is  a  private  institution  maintained 
for  charitable  purposes  and  those  treated  there  are  required 

* "  The  Insanity  Law,"  art.  3,  sec.  59. 

'  Mosher,  J.  M.,  "  The  Treatment  of  Mental  Disease  in  a  General 
Hospital,"  The  Modern  Hospital,  Nov.,  1915. 


120     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [262 

to  pay  or  to  be  paid  for  by  relatives  or  friends,  if  they  pos- 
sess the  means;  the  charges  include  the  usual  and  rather 
moderate  amounts  asked  for  the  care  of  the  patients  and  for 
the  payment  of  private  nurses,  if  such  are  found  to  be  neces- 
sary.^ The  development  of  psychopathic  hospitals  in  the 
large  cities,  of  psychopathic  wards  in'general  hospitals  in  the 
smaller  cities  of  the  state,  and  an  extension  of  the  ten-day 
detention  period,  would  prove  to  be  important  elements  in 
the  reduction  of  the  number  of  committed  cases,  in  lessening! 
the  overcrowding  of  the  state  hospitals,  and  in  markedly  in- 
creasing the  early  recovery  of  incipient  cases  of  mental 
disorder. 


V.    CLASSIFICATION  OF   PATIENTS  AT  STATE   HOSPITALS 

In  the  preceding  chapter  it  was  pointed  out  that  of  those 
admitted  to  the  psychopathic  wards  of  Bellevue  Hospital 
during  one  year,  the  following  number  of  patients  were 
committed  to  state  hospitals: 


Male. 

Female. 

Totals. 

To  Manhattan  State  Hosp. .. 

To  Central  Islip  S.  H 

To  Kings  Park  S.  H 

252 

184 

4 

201 

147 

2 

453 

331 

6 

Totals 

440 

350 

790 

Upon  arriving  at  the  state  hospitals,  the  patients  are  as  a 
rule  sent  to  the  reception  wards  or  buildings,  in  which  they 
are  detained  until  properly  diagnosed  and  classified.  The 
superintendents  of  state  hospitals  have  for  a  long  time  made 

'Mosher,  "  Need  of  Early  Treatment  for  Mental  Diseases,"  Amer.  Jo. 
of  Ins.,  Jan.,  1909,  pp.  501-503;  Drury,  William  F.,  Evolution  of 
Psychiatry,  1904,  p.  42. 


263]        STATE  HOSPITAL  CARE  AND  TREATMENT  121 

efforts  to  promote  and  carry  out  a  greater  uniformity  in 
classification  according  to  age,  nationality,  education,  station 
in  life  and  diagnosis  of  those  assigned  to  particular  wards/ 
However,  the  overcrowding  in  all  the  hospitals,  the  large 
wards  and  the  insufficiency  of  the  staffs  have  made  it  well- 
nigh  impossible  to  carry  out  these  plans,  except  insofar  as 
relates  to  placing  patients  in  wards  according  to  diagnosis, 
behavior,  and  the  acuteness  or  chronicity  of  the  ailment. 
In  planning  one  of  the  large  state  hospitals  in  New  York 
some  years  ago,  the  medical  superintendent  submitted  plans 
which  called  for  a  number  of  cottages,  each  with  a  capacity 
of  twenty-live  patients,  the  purpose  in  mind  being  to  per- 
mit the  classification  of  the  patients  along  the  lines  outlined 
above.  When  the  total  outlay  for  erecting  and  maintaining 
such  a  cottage  system  was  estimated,  the  amount  necessary 
was  found  to  be  far  greater  than  the  state  had  appropriated 
for  the  new  institution  and  intended  to  allow  for  mainten- 
ance and  upkeep  from  year  to  year.  The  result  was  that  in- 
stead of  erecting  separate  cottages  with  accommodations 
for  not  more  than  thirty  patients,  buildings  housing  from 
125  to  150  patients  were  erected,  with  less  satisfactory  pro- 
visions for  the  separation  and  classification  of  the  different 
groups  in  the  hospital  population. 

VI.    OCCUPATIONAL   THERAPY  AT   STATE    HOSPITALS 

After  the  assignment  of  patients  to  their  wards,  an  at- 
tempt is  made  to  give  them  some  form  of  occupation  suitable 
to  their  particular  needs  and  requirements.  Several  clas- 
ses for  the  reeducation  of  the  patients  are  maintained  in 
most  of  the  hospitals,  though  the  total  number  of  patients 
benefiting  from  such  instruction  is  small.  Thus,  in  191 8, 
in  the  Manhattan  State  Hospital,  with  about  5,500  patients 
in  the  wards,  there  were  only  1 50  who  received  instruction 

^  State  Hospital  Quarterly,  Aug.,  1919,  p.  439. 


122     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [264 

in  the  arts  and  crafts  classes/  In  a  survey  made  of  the 
Manhattan  State  Hospital  by  the  New  York  State  Depart- 
ment of  Efficiency  and  Economy,  it  was  reported  that  the 
institution  obtained  excellent  production  from  the  land 
under  cultivation,  as  well  as  from  the  hospital  industries. 
This  statement  in  itself  is  not  sufficient  evidence  of  the 
efficiency  of  industrial  departments  in  the  hospital,  for  it 
fails  to  take  into  consideration  the  number  or  percentage  of 
inmates  employed  in  these  industries,  even  though  it  seem- 
ingly makes  allowance  for  the  high  per  capita  production. 
Mention  is  made  of  the  fact  that  of  245  arable  acres  only 
66  acres  were  under  cultivation  at  the  time  the  study  was 
made.^ 

The  possibility  of  providing  occupational  therapy  for  a 
larger  percentage  of  the  patients  under  treatment  is  in- 
dicated by  the  experiences  of  the  Bloomingdale  Hospital 
at  White  Plains,  where,  with  a  total  of  437  patients  in 
1918,  there  was  a  daily  average  attendance  of  97  patientsi 
in  the  departments  of  occupational  therapy,  in  which  a  large 
variety  of  occupations  are  taught.^  The  marked  difference 
between  conditions  at  the  Manhattan  State  Hospital  and 
the  Bloomingdale  asylum  is  due  to  a  number  of  reasons, 
among  them  being  the  difficulty  experienced  in  trying  to 
educate  certain  types  of  mental  cases,  of  which  larger 
numbers  are  to  be  found  in  the  state  institutions  than  at 
Bloomingdale,  which  proportionately  treats  a  larger  number 
of  cases  oi  manic  depressive  insanity,  and  a  smaller  number 
of  cases  of  senility,  general  paralysis,  and  dementia  prae- 
cox :  the  lack  of  a  sufficient  number  of  properly  trained  sup- 

'S.  H.  C,  30th  A.  R..  p.  201. 

*McCalmut,  M.  E.,  Report  of  the  New  York  State  Dept.  of  Efficiency 
and  Economy,  "Organization  and  Administration  of  New  York  State 
Hospitals  for  the  Insane,"  1915,  p.  418. 

^Annual  Report,  Society  of  the  New  York  Hospital,  1918,  pp.  11- 12. 


265] 


STATE  HOSPITAL  CARE  AND  TREATMENT 


123 


ervisors  and  teachers  of  trades ;  the  failure  of  the  state  hos- 
pitals to  develop  a  definite  policy  regarding  the  training  and 
education  of  the  patients,  and  also  the  large  number  and 
variety  of  trades  and  occupations  represented  among  the 
patients  in  the  state  institutions.  Considering  only  the  790 
patients  dealt  with  in  this  work,  the  diversity  of  employment 
prior  to  admission  to  the  state  hospitals  is  evident  from  the 
followinsf  tables : 


Table  20.    Occupations  of  Males 


Actor I 

Agent 4 

Artist  I 

Auctioneer i 

Author I 

Baker 2 

Barber  2 

Bartender  ■  i 

Bookbinder    2 

Bookkeeper   8 

Brass  worker  2 

Brushmaker i 

Butcher  3 

Button  hole  maker i 

Buttonmaker   i 

Canvasser  i 

Capmaker  3 

Caretaker   i 

Carpenter   3 

Chauffeur   2 

Chemist  i 

Cigar  maker  7 

Clerk  42 

Cutter    9 

Deck  hand  i 

Designer   i 

Dishwasher   i 

Draughtsman    i 

Driver    5 

Electrician    4 

Embroiderer   2 

Engineer  R.  R.  I 


Factory  hand   3 

Farmer   I 

Florist   I 

Furniture  maker i 

Furrier   2 

Gasfitter   i 

Grocer  2 

Hairworker  i 

Harnessmaker i 

Hatmaker i 

Helper  i 

Insurance  agent  i 

Interpreter  i 

Ironworker    3 

Janitor i 

Jeweler   2 

Junk  dealer 2 

Laborer Z7 

Laundry  worker i 

Letter  carrier I 

Longshoreman    2 

Lunchman    i 

Machinist  6 

Manager  i 

Manufacturer   i 

Mechanic    2 

Mechanical  dentist   2 

Messenger    1 1 

Motorman    i 

Musician    2 

Newspaper  illustrator   i 

Operator  26 


124 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[266 


Packer  4 

Painter    9 

Paper-box  maker 4 

Paper  roller 1 

Peddler  17 

Photographer    3 

Pipemaker    i 

Plumber   i 

Pocketbook  maker 1 

Porter  i 

Presser  9 

Printer    11 

Salesman    32 

School  pupil   7 

Sheet  metal  maker  2 

Shoemaker  4 

Singer   i 

Soda  dispenser i 

Soldier 6 

Special  officer  i 


Stenographer i 

Storekeeper  i 

Student   3 

Street  car  conductor I 

Suspendermaker i 

Tailor    35 

Teacher    3 

Telegraph  operator I 

Telephone  operator    I 

Ticket  speculator I 

Tinsmith  3 

Truckman I 

Upholsterer  3 

Watchmaker   2 

Waiter  7 

Window  cleaner 3 

No  occupation 22 

Totals  440 


Table  21. 
Artificial  flower  maker  . . . 

Bookbinder    

Bookkeeper  


I 
I 

..  5 

Capmaker  i 

Cashier   i 

Cigar-box  maker  i 

Clerk  7 

Clothes  cleaner i 

Doll  maker i 

Domestic 8 

Dressmaker  11 

Envelope  maker i 

Errand  girl i 

Factory  hand   4 

Glove  maker  i 

Housework    185 

Interpreter   1 

Jewelry  dealer i 

Laundress    2 

Leather  goods  worker i 


Occupations  of  Females 

Milhner 5 

Model    I 

Musician  2 

Neckwear  2 

Needlework i 

Operator 29 

Paper  box  maker 4 

Peddler   i 

Pocketbook  maker I 

Salesgirl    2 

School  pupil   8 

Seamstress  2 

Stenographer  13 

Teacher,  music 3 

Waist  examiner 4 

Waitress i 

Watchmaker   I 

No  occupation  35 


Totals  350 


The  above  tables  indicating  the  list  of  occupations  of  both 


267]        STATE  HOSPITAL  CARE  AND  TREATMENT  125 

males  and  females  show  that  it  would  be  impossible  as  weU 
as  impracticable  to  establish  industries  within  the  hospital 
walls  and  grounds  akin  to  those  in  which  the  patients  were 
engaged  prior  to  commitment.  It  is  quite  apparent  from  a 
perusal  of  these  lists  that  there  are  many  trades  and  oc- 
cupations which  are  not  listed  here,  simply  because  among" 
the  patients  considered  certain  industrial  and  commercial! 
activities  are  not  as  common  as  among  other  people.  Thus, 
among  the  males,  there  is  to  be  found  but  a  small  number  of 
patients  who  were  employed  in  the  building  and  mechanical 
lines,  whereas  there  is  a  comparatively  large  number  re- 
presented among  the  clerks,  salesmen,  tailors,  clothing 
operators,  and  kindred  or  allied  trades.  The  same  differ- 
ence is  also  found  among  the  females.  There  were  only 
eight  domestics,  though  a  considerable  number  of  the  single 
yotmg  women  were  foreign  bom,  and  a  large  number  in  the 
needle  trades.  The  185  patients  indicated  as  being  engaged 
in  housework  represent  married  women  caring  for  their  own 
households,  not  leaving  their  homes  to  become  domestics  or 
servants  in  the  homes  of  others. 

The  intent  and  purpose  of  the  discussion  of  the  trades  and 
occupations  of  the  patients  will  become  more  apparent  in  the 
last  chapter  of  this  work,  for  there  thought  will  be  given  to 
ways  and  means  of  providing  gainful  occupation  for  dis- 
charged and  paroled  patients,  as  well  as  for  those  who  may 
under  unfavorable  circumstances  and  conditions  become  so 
ill  mentally  as  to  make  their  commitment  to  a  state  hospital 
advisable.  As  pointed  out  above,  the  aim  has  also  been  to 
indicate  the  inadequacy  of  present  accommodations  and 
provisions  in  the  state  hospitals  for  the  therapeutic  treat- 
ment of  patients  through  a  sufficiently  varied  and  interesting 
scheme  of  light  occupations. 


126     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [268 
VII.    READMISSIONS  TO  STATE  HOSPITALS 

One  very  important  way  properly  to  gauge  the  efficacy 
of  the  care  and  treatment  accorded  patients  in  state  hospitals 
is  to  consider  the  proportion  of  patients  that  find  it  neces- 
sary to  return  to  the  hospitals  from  which  they  have  been 
discharged  or  paroled,  or  taken  home  by  relatives.  There 
are  necessarily  a  number  of  factors  that  enter  into  such  a 
consideration,  among  them  being  the  over-crowding  in  the 
hospitals,  the  ratio  of  officers,  nurses,  and  attendants  to  the 
number  of  patients,  diagnoses  of  the  patients  permitted  to 
leave  the  hospital,  and  ease  with  which  patients  may  be 
returned  to  the  institutions.  Of  the  8,700  total  admissions 
to  the  state  hospitals  for  the  year  1918,  6,797  O'^'  7^-^  P^^ 
cent  were  first  admissions;  1,903,  or  21.9  per  cent  were 
readmissions.^  There  was  a  marked  difference  between  the 
readmission  rates  among  the  sevettkUiospitals ;  the  Brooklyn 
State  Hospital  had  a  readmission  percentage  of  only  16.7, 
largely  because  of  the  disproportionate  number  of  senile 
cases  quartered  there,  whereas  there  was  a  percentage  of 
28.4  of  readmissions  in  the  Middletown  State  Hospital.^ 
The  readmission  rates  for  the  two  hospitals  which  figure 
largely  in  this  study,  namely  Manhattan  and  Central  Islip 
State  Hospitals,  were  18.9  per  cent  for  the  former,  and  21.4 
per  cent  for  the  latter.  Table  22  indicates  the  readmissions 
to  the  state  hospitals  of  the  Jewish  patients,  who  were  ad- 
mitted to  these  institutions  from  Bellevue  Hospital  during 
the  year  beginning  September  i,  191 7  and  ending  August 
31,  1918: 

>  S.  H.  C,  30th  A.  R.,  p.  278. 
*Ibid.,  p.  343. 


269]        STATE  HOSPITAL  CARE  AND  TREATMENT  127 

Table  22.    Number  of  Readmissions  to  State  Hospitals 


No.  of 
Admissions. 


1    

2    

3  

4 

6   

7  

12  

Totals 


Central  Islip, 


106 

61 

13 

4 


184 


99 
33 
10 

5 


147 


Manhattan. 


180 

58 

13 

I 


252 


127 
60 

9 
2 
I 
I 
I 


Kings  Park. 


Totals. 


s 

286 

226 

123 
26 

95 
19 

5 

7 

I 

I 

'• 

I 

440 

350 

There  were  512  first  admissions  and  278  readmissionsi 
to  the  three  state  hospitals  tO'  which  the  patients  were  com- 
mitted, showing  a  readmission  rate  of  35.2  per  cent  for  the 
Jewish  cases  sent  to  these  institutions  from  Bellevue  Hos- 
pital. This  percentage  is  considerably  higher  than  the 
rate  for  the  entire  state  hospital  system,  and  also  higher 
than  the  rate  of  readmissioins  to^  the  Manhattan  and  Central 
Islip  State  Hospitals.  In  view  of  these  facts,  it  might  be 
advisable  to  consider  in  brief  the  elements  that  possibly  con- 
tributed to  this  greater  percentage  of  readmissions  among 
the  group  studied  in  this  work. 

Several  reasons  have  already  been  assigned  for  the  return 
of  patients  to  hospitals  after  they  have  once  been  discharged 
either  as  recovered  or  in  an  improved  condition.  There 
are,  however,  more  specific  and  definite  factors  that  can  be 
held  responsible  for  the  high  rate  of  readmissions  that  have 
been  shown  to  be  prevalent  among  the  Jewish  patients  ad- 
mitted to  the  state  hospitals.  It  has  been  contended  by  some 
students  of  the  subject  that  the  cause  of  the  larger  pro- 


128     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [270 

portion  of  readmissions  among  Jewish  patients  could  be 
assigned  almost  entirely  to  the  disproportionate  number 
of  certain  of  the  psychoses  appearing  among  these  patients, 
particularly  dementia  praecox  in  all  its  variations,  and  also 
the  several  forms  of  manic  depressive  insanity/ 

(a)  High  Readmission  Rates  Among  Jewish  Patients. 
In  order  to  find  what  is  probably  the  cardinal  reason  for  the 
high  readmission  rates  among  the  Jewish  patients,  it  will 
again  be  necessary  to  revert  to  the  figures  for  the  state 
hospitals  so  as  to  have  a  basis  upon  which  to  make  an  ac- 
curate comparison.  For  the  state  as  a  whole,  the  per  cent 
distribution  among  readmissions  for  the  year  19 18  was  as 
follows :  for  dementia  praecox  the  rate  for  the  entire  state 
was  31.2  p€r  cent,  with  rates  of  37.3  per  cent  for  Manhattan 
State  Hospital,  and  35.0  per  cent  for  Central  Islip  State 
Hospital;  for  manic  depressive  readmissions  the  rate  was 
36.5  per  cent  for  the  state  as  a  whole,  36.6  per  cent  for  Man- 
hattan State  Hospital  and  33.1  per  cent  for  Central  Islip 
State  Hospital.^  From  the  percentages  presented  in  Table 
23  it  is  seen  that  the  Jewish  patients  contributed,  in  fact,  a 
smaller  percentage  of  readmissions  of  cases  of  dementia 
praecox  than  either  the  state  as  a  whole  or  Manhattan  and 
Central  Islip  State  Hospitals,  while  they  seemingly  were 
responsible  for  a  higher  readmission  rate  among  the  cases 
of  manic  depressive  insanity  than  that  which  prevailed 
throughout  the  state,  or  in  Manhattan  and  Central  Islip 
State  Hospitals.  In  reference  to  the  latter  group,  the  rate 
of  readmissions  to  the  Manhattan  State  Hospital  for  the 
preceding  year,  namely  191 7,  was  likewise  41.8  per  cent, 
identical  with  the  rate  of  Jewish  readmissions  for  the  year 
1 918.  Table  23  indicates  the  percentages  in  summarized 
form: 

i;S.  H.  C,  30th  A.  R.,  p.  376,  for  discussion  of  readmissions  to  all 
state  hospitals. 
*Ihid.,  p.  294. 


271]        STATE  HOSPITAL  CARE  AND  TREATMENT  129 

Table  23.    Distribution  of  Certain  Psychoses  Among  Readmissions 


Manic  Depressive 
Insanity. 


Allstate  Hospitals- .. 
Manhattan  S»ate  Hosp 
Central  Islip  S.  H.... 
Jewish  cases   


36.5 
36.6 

41.8 


Judging  from  the  facts  and  figures  presented  above,  it  is 
seen  that  the  high  rate  of  readmissions  among  the  Jewish 
patients  as  compared  with  the  rate  of  readmissions  to  all 
the  state  hospitals  cannot  be  ascribed  to  a  higher  rate  of 
readmissions  among  the  cases  diagnosed  as  suffering  from 
either  dementia  praecox  or  manic  depressive  insanity.  The 
variation  in  the  percentages  of  certain  psychoses,  particul- 
arly dementia  praecox  and  manic  depressive  insanity,  as 
shown  in  the  statistics  for  all  the  state  hospitals  for  a  five 
year  period  indicate  such  a  wide  divergence,^  that  the  only 
safe  method  that  may  be  pursued  in  arriving  at  comparative 
figures  is  to  take  only  the  percentages  for  the  hospitals  to 
Mrhich  the  Jewish  patients  were  admitted  in  large  numbers. 
Following  along  these  lines,  the  readmission  rates  to  the 
Manhattan  and  Central  Islip  State  Hospitals,  as  shown  in 
Table  23,  should  be  those  which  alone  might  properly  be 
used  to  arrive  at  a  just  comparison.  Even  then,  the  Jewish 
patients  as  already  explained,  show  up  favorably  when  com- 
pared with  the  total  readmissions,  though  they  have  a 
higher  readmission  rate  among  the  cases  of  manic  depres- 
sive insanity.  The  variation  in  the  basis  for  diagnosisi 
among  the  different  hospitals,  the  marked  difference  between 
the  reported  percentages  of  certain  of  the  psychoses  among 
the  several  hospitals,  despite  the  attempts  of  the  staff  of  the 


1  S.  H.  C,  30th  A.  R.,  p.  294. 


130     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [272 

Psychiatric  Institute  to  standardize  the  methods  used  in 
arriving  at  diagnoses  for  particular  groups  of  cases,  indicate 
that  the  statistics  as  thus  far  presented  cannot  be  taken  at 
full  face  value,  at  least  insofar  as  the  diagnoses  of  a  large 
number  of  cases  which  may  be  classified  as  borderline  are 
concerned. 

VIII.    REASONS  FOR   HIGH    READMISSION    RATES 

The  reasons  for  the  higher  rate  of  readmissions  among 
the  Jewish  patients  than  among  the  others  committed  to  the 
state  hospitals  are  as  yet  unexplained,  though  a  higher  rate  of 
readmissions  among  those  patients  diagnosed  otherwise  than 
dementia  praecox  and  manic  depressive  insanity,  may  in 
part  cover  the  added  percentage  of  these  readmissions.  The 
importance  of  the  question  of  a  higher  rate  of  readmissions! 
among  Jews  involves  even  more  fundamental  matters  than 
that  of  distribution  of  patients  according  to  diagnosis.  It 
again  raises  the  question  discussed  in  another  connection, 
namely,  the  effect  of  a  proper  classification  of  patients  ac- 
cording to  social,  racial,  language,  etc.,  groups,  upon  the 
percentage  of  recoveries. 

An  indication  of  some  of  these  difficulties  encountered  by 
the  staff  of  workers  in  the  wards  is  the  statement  recently 
made  to  the  writer  by  a  physician  in  one  of  the  largest  state 
hospitals.  He  remarked  that  he  had  in  one  of  his  wards  a 
group  of  fifty  patients  whose  language  was  entirely  alien  to 
him  as  well  as  to  the  nurses  and  attendants  on  the  ward. 
The  result  was  that  these  patients  did  not  receive  the  atten- 
tion that  should  have  been  bestowed  upon  them  by  the 
doctor  and  others  in  heli>ing  them  to  improve  and  ultimately 
to  recover.  This  condition  is  particularly  applicable  to 
the  Jewish  patients  of  foreign  birth,  though  the  hospital 
authorities  have  tried  to  do  all  they  could  to  remove  such 
hindrances   to  the  well-being   and   recovery   of   the   large 


273]        STATE  HOSPITAL  CARE  AND  TREATMENT  131 

number  of  noii-'English  speaking  charges  under  their  care. 
The  question  of  agreeable  and  palatable  food  is  a  matter 
which  applies  particularly  to  Jewish  patients,  most  of  whom 
have  been  brought  up  in  homes  where  the  Jewish  dietary- 
laws  are  observed,  for  the  eating  of  food  that  is  not  pre- 
pared according  to  these  laws  is  more  or  less  obnoxious. 
The  result  is  tliat  patients  who  understand  the  difference, 
among  them  being  a  large  number  of  those  ultimately 
paroled  or  discharged,  demand  of  their  relatives  that  steps 
be  taken  leading  to  their  release  from  custody,  often  before 
they  are  sufficiently  recovered  to  insure  against  a  relapse. 
In  the  long  run  such  premature  discharges  necessitate  read- 
mission  to  the  hospital. 

Assuming  that  the  reasons  for  the  high  readmission  rates 
among  the  Jewish  patients  can  be  ascribed  to  the  causes  just 
outlined,  as  well  as  to  the  fairly  large  number  oif  cases  of 
manic  depressive  insanity  that  have  to  be  returned  to  the 
hospitals,  the  thought  comes  to  mind  that  there  must  be 
some  way  or  ways  of  so  altering  the  present  methods  of 
dealing  with  the  insane  cared  for  in  state  institutions,  that 
high  readmission  rates  may  be  materially  reduced.  Several 
methods  are  obvious  from  the  discussion  of  the  subject, 
such  as  introducing  into  the  hospitals  physicians  and  nurses 
as  well  as  attendants  who  understand  the  languages  spoken 
by  large  groups  of  patients  oi  foreign  birth ;  applying  a  more 
thorough  and  selective  classification  to  all  the  patients,  sup- 
plying "kosher"  kitchens  in  the  hospitals  in  which  large 
numbers  oi  Jewish  patients  are  cared  for,  etc.  The  im- 
possibility of  doing  these  several  things  at  the  present  time 
because  of  the  overcrowded  conditions  in  the  hospitals  hag 
already  been  touched  upon,  and  nothing  can  be  done  along 
these  lines  until  plans  already  prepared  for  the  further  ex- 
tension of  the  facilities  of  the  state  hospitals  are  sufficiently 
matured  to  furnish  a  basis  for  further  suggestion  and  criti- 
cism. 


132     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [274 

IX.    MOVEMENTS    FOR   ESTABLISHMENT    OF   JEWISH    PSYCHO- 
PATHIC HOSPITALS 

Referring  particularly  to  Jewish  patients,  movements 
have  been  set  afoot  in  New  York  City  aiming  at  the  estab- 
lishment of  a  hospital  for  the  mentally  sick  Jews  whose 
diagnosis  indicates  a  prognosis  of  possible  recovery  or  at 
least  of  improvement  so  marked  in  both  physical  and  mental 
conditions,  as  to  render  it  advisable  to  care  for  and  treat 
such  patients  in  an  institution  resembling  in  plan  and  scope 
the  psychopathic  hospitals  of  Boston  and  Baltimore.  Many 
members  of  the  Jewish  community  in  New  York  who  have 
given  this  matter  thought  seem  to  agree  that  such  an  in- 
stitution would  not  only  be  of  much  service  to  those  unfor- 
tunates among  the  Jews  who  become  mentally  unbalanced, 
but  would  at  the  same  time  effect  a  higher  proportion  of 
cures,  reduce  the  expenditure  of  state  money,  and  also  act 
as  an  experimental  station  for  the  study  of  various  phases 
of  the  problem.  The  plans  for  such  a  hospital  have  not  as 
yet  progressed  sufficiently  to  make  it  advisable  to  pass  judg- 
ment upon  the  matter.  However,  it  is  safe  to  state  that  any 
project  is  worthy  when  its  purpose  is  to  reduce  human  suf- 
fering which  is  involved  in  the  loss  of  the  power  to  reason 
and  to  live  the  life  of  a  rational  being.  Mental  hygiene 
agencies  have  been  at  work  in  New  York  City  as  well  as  in 
different  parts  of  the  country  for  some  years  past,  their 
activities  being  almost  altogether  limited  to  extra-institu- 
tional care  of  those  who  are  either  in  danger  of  a  mental 
breakdown  or  are  discharged  patients  from  state  or  private 
institutions  for  the  insane.  The  possibilities  for  good  work 
inherent  in  these  organizations  or  societies  for  the  social 
care  of  the  insane  will  be  dealt  with  at  length  in  a  subsequent 
chapter. 


275]        STATE  HOSPITAL  CARE  AND  TREATMENT  133 

X.    DIAGNOSIS  OF  ADMISSIONS  TO  STATE   HOSPITALS 

Mention  has  already  been  made  of  the  difficulties  en- 
countered in  attempting  to  supply  an  adequate  definition  o£ 
the  term  "  insanity,"  and  of  the  disagreement  among  stud- 
ents of  psychiatry  regarding  a  proper  scheme  or  system  of 
classification  of  the  forms  of  mental  alienation.  These  per- 
plexities extend  to  the  field  of  diagnosis  of  mental  cases 
as  well ;  in  the  tables  that  follow  there  will  be  found  indica- 
tions of  a  marked  variance  in  the  number  of  cases  diagnosed 
and  classified  under  particular  divisions,  in  the  ratio'  of  casesi 
reported  as  recovered  and  improved,  etc.,  even  in  the  statis- 
tics for  two  of  the  largest  of  the  metropolitan  hospitals. 

As  long  ago  as  1874  Maudsley  wrote: 

It  would  certainly  be  vastly  convenient  and  would  save  a  world 
of  trouble,  if  it  were  possible  to  draw  a  hard  and  fast  line,  and 
to  declare  that  all  persons  who  were  on  one  side  of  it  must  be 
sane  and  all  persons  who  were  on  the  other  side  of  it  must  be 
insane.  But  a  very  little  consideration  will  show  how  vain  it 
is  to  attempt  to  make  such  a  division.  That  nature  makes  no 
leaps,  but  passes  from  one  complexion  to  its  opposite  by  a 
gradation  so  gentle  that  one  shades  imperceptibly  into  another, 
and  no  one  can  fix  positively  the  point  of  transition,  is  a  suffi- 
ciently trite  observation.  Nowhere  is  this  more  true  than  in 
respect  to  sanity  and  insanity;  it  is  unavoidable  therefore  that 
doubts,  disputes,  and  perplexities  should  arise  in  dealing  with 
particular  cases.^ 

Since  this  statement  was  originally  written  psychiatry  has 
advanced  in  leaps  and  boimds,  and  more  scientific  methods 
of  diagnosis  have  been  evolved;  however,  the  possibility 
of  erring  on  the  part  of  the  individual  making  and  record- 
ing observations  is  well  known,  particularly  in  the  proper 
interpretation  of  given  facts.     The  engagement  of  expertsi 

^  Maudsley,  Henry,  Responsibility  in  Mental  Disease,  1874,  pp.  38-39. 


134 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[276 


in  the  diagnosis  of  mental  diseases  by  both  sides  in  murder 
cases,  and  the  usual  conflicting  testimony  is  a  state  of 
affairs  which  has  existed  for  a  long  time  and  doubtless  will 
continue,  so  long  as  the  standards  according  to  which  diag- 
noses of  mental  disorders  are  made,  are  not  sufficiently  de- 
veloped to  remove  much  of  the  possibility  of  error  of 
judgment. 

XI.    RESULT  OF  ONE  YEAR  OF  STATE  HOSPITAL  CARE 

It  may  be  affirmed  without  fear  of  contradiction  that  no 
principle  in  psychiatry  is  more  firmly  established  than  the 
fact  that  early  treatment  of  the  insane  based  upon  a  correct 
analysis  of  the  physical  and  mental  conditions  is  the  key  to 
success.^  The  figures  in  the  following  tables  represent  in  a 
way  the  gauge  by  which  we  can  measure  the  ability  of  the 
state  hospital  staffs  properly  to  diagnose  patients,  and  of  the 
hospitals  to  provide  the  proper  standards  of  care  and  treat- 
ment. 

Table  24.     Disposition  of  Patients  by  State  Hospitals 


Disposition. 


Remaining  in  Hospital  . . . 
Recovered  Discharged.  .  • . 
Much  Imp.  and  Imp.  Disch 
Unimproved,  Discharged.. 

Died  in  Hospital 

Deported  to  other  State. . . 
Not  Insane   

Totals 


Central  Islip. 

Manhattan. 

Tot 

«J 

V 

OS 

V 

at 

CS 

a 

a 

s 

C4 

s 

Ui 

S 

fe 

s 

101 

62 

127 

93 

228 

21 

25 

7 

10 

28 

39 

41 

57 

64 

96 

4 

4 

10 

3 

14 

18 

13 

49 

27 

67 

I 

I 

I 

4 

2 

I 

I 

I 

184 

147 

252 

201 

436 

155 

35 
105 

7 
40 

5 
I 


348 


*  Warner,  Chas.  G.,  "Reception,  Examination,  and  Care  of  New  Ad- 
missions," Amer.  Jo.  of  Ins.,  1916-1917,  p.  673. 


^-^y^        STATE  HOSPITAL  CARE  AND  TREATMENT  135 

Table  24  indicates  the  disposition  of  the  patients  ad- 
mitted to  the  state  hospitals,  and  the  result  of  the  care  and 
treatment  given  to  these  patients  during  the  period  of  one 
year.  These  figures  show  that  at  the  end  of  the  first  year  of 
care  and  treatment  in  the  two  state  hospitals  mentioned 
above,  of  the  total  admissions,  there  were  163  or  49.2  per 
cent  of  the  patients  still  under  care  in  Central  Islip  State 
Hospital,  and  220  or  48.5  per  cent  in  the  Manhattan  State 
Hospital.  A  word  should  be  said  at  this  point  regarding 
the  figures  for  Kings  Park  State  Hospital;  the  admissions 
to  this  institution  from  Bellevue  Hospital  are  altogether 
cases  which  have  suffered  a  relapse  and  which  it  is  found 
advisable  to  return  to  the  institution  where  they  have  pre- 
viously been  confined.  Also,  the  number  of  such  patients 
for  the  entire  year  is  so  small  that  no  dependable  statistics 
can  be  drawn  up. 

The  table  that  follows  points  out  the  rate  of  recovery  and 
improvement  of  patients  committed  to  the  Central  Islip  and 
Manhattan  State  Hospitals : 

Table  25.     Rate  of  Recovery  and  Improvement  of  Patients 


State  Hospitals. 


Central  lilip 
Manhattan  ■  • 


Recovered. 


No. 


2546 
1017 


Per  cent  of 

Total 
Admitted. 


1 1.4 

2.7 


^ 


Much  Improved  and 
Improved. 


No. 


i7-0|  »3-9 
4-9l    3-8 


80 
121 


Per  cent  of 

Total 
Admitted. 


6 

4J 

0 

H 

iS-7 

27.9 

24.1 

22.6 

31.8 

27.2 

136     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [278 

The  general  average  rate  of  recovery  based  on  all  admis- 
sions was  19.4  per  cent  for  the  year  191 8,  the  rate  for  the 
males  being  18.2  per  cent  and  for  the  females  20.7  per  cent.^ 
From  the  figures  presented  above,  it  is  quite  evident  that 
the  recovery  rate  for  the  Jewish  patients  was  unduly 
small,  for  while  the  per  cent  of  the  total  admissions  re- 
covered for  Central  Islip  was  20.3,  for  Jewish  patients  it 
was  only  13.9  per  cent;  and  whereas  the  rate  of  recoveries 
for  Manhattan  State  Hospital  for  the  year  1918  was  15.1 
per  cent,  for  the  Jewish  cases  it  was  only  3.8  per  cent,  an 
abnormally  low  figure.  The  question  naturally  arises  as  to 
why  there  should  be  such  a  marked  discrepancy  between  the 
rate  of  recovery  for  all  patients  and  the  rate  for  a  partic- 
ular group.  Some  reasons  have  already  been  given,  though 
in  connection  with  the  discussion  of  another  phase  of  the 
subject. 

To  recapitulate,  it  might  be  well  to  mention  the  fact  that 
so  many  O'f  the  Jewish  patients  who  find  their  way  into  the 
state  hospitals  do  not  speak  English  sufficiently  well  to  per- 
mit the  physicians  who  care  for  and  treat  them  in  the 
hospitals  to  recognize  when  the  patients  have  recovered. 
The  result  is  that  a  number  of  Jewish  patients  are  dis- 
charged as  improved  or  much  improved,  when  by  the 
method  of  classification  adopted  in  the  institutions  many  of 
them  might  properly  be  signed  out  as  recovered.  The 
figures  of  the  improved  and  much  improved  cases  seem  to 
bear  out  this  statement.  The  general  rate  for  patients  dis- 
charged, improved  and  much  improved,  based  on  all  ad-' 
missions,  was  20.0  in  1918  and  18.6  per  cent  in  191 7,  while 
the  rate  for  Jewish  patients  admitted  to  Central  Islip  and 
Manhattan  State  Hospitals  was  24.1  for  the  former  and 
27.2  per  cent  for  the  latter,  for  the  year  19 18.     During  this; 

'S.  H.  C,  30th  A.  R.,  p.  307. 


279]        STATE  HOSPITAL  CARE  AND  TREATMENT         137 

year  the  general  rate  for  Central  Islip  was  21.9  per  cent, 
and  for  Manhattan  21.7  per  cent.  After  making  due  allow- 
ance for  the  larger  number  of  Jewish  patients  discharged  as 
improved  and  much  improved,  there  still  remains  a  wide 
margin  between  the  total  rate  of  recoveries  and  the  small 
rate  for  Jewish  cases.  The  fact  that  Jewish  patients  da 
not  get  along  so  well  as  do  other  patients  in  state  hospitals 
has  already  been  mentioned  and  Table  25  brings  out  this 
condition  more  clearly. 

XII.    FOLLOW-UP  WORK   IN   NEW   YORK   CITY 

(a)  Need  for  This  Form  of  Service.  At  this  point  it 
might  be  advisable  to  consider  in  brief  a  problem  which 
has  much  bearing  upon  the  question  of  the  final  disposition 
of  the  patients.  Little  need  be  said  regarding  those 
patients  who  are  suffering  from  a  more  or  less  chronic 
ailment,  necessitating  their  detention  in  the  institutions. 
Table  24  brings  out  that  of  a  total  of  784  commitments, 
383  or  48.8  per  cent  of  the  patients  were  still  in  the  hos- 
pitals at  the  end  of  one  year,  with  the  probability  that  many 
would  remain  inmates  of  state  institutions  for  many  more 
years,  and  in  some  cases  even  until  they  died.  The  patients 
whom  it  is  necessary  to  consider  in  greater  detail  however, 
particularly  from  the  point  of  view  of  this  study,  are  in- 
cluded in  the  recovered,  much  improved  and  improved 
groups.  Experience  of  several  years  in  the  work  of  a 
mental  hygiene  agency  has  conclusively  proved  to  the  writer 
the  importance  of  closely  following-up  and  supervising, 
patients  thus  discharged.  They  required  advice  and  guid- 
ance in  obtaining  employment,  in  being  directed  intO'  new 
and  more  suitable  occupations,  and  in  making  those  numerous 
readjustments  which  are  essential  to  the  mental  well-being 
of  former  inmates  of  state  hospitals,  if  relapses  are  to  be 
prevented    and    the   possibility    of   the    development    of    a 


138     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [280 

chronic  mental  disorder  is  to  be  eliminated.  Moreover,  the 
patients  should  be  made  to  feel  that  trained  psychiatrists  and 
social  workers  are  always  available  to  aid  them  in  their 
difficulties,  whether  mental,  medical  or  social. 

(b)  Extent  of  Follow-up  Work  in  New  York.  The 
state,  largely  through  the  continued  activities  of  the  State 
Charities  Aid  Association  and  its  committee  on  mental 
hygiene,  has  come  to  realize  the  genuine  opportunities  for 
service  inherent  in  a  system  of  after-care  work  and  has 
accordingly  made  some  provisions  along  these  lines.  But 
to  what  extent  has  this  been  done,  and,  how  much  has  been 
accomplished?  In  view  of  the  possibilities  for  financial 
saving  alone,  not  considering  at  this  moment  the  more 
humane  aspects  of  the  problem,  the  state  has  been  very 
lax  in  failing  to  provide  a  sufficiently  large  corps  of  workers 
to  follow  up  discharged  and  paroled  patients  and  so  help  to 
prevent  relapses.  A  very  important  additional  service 
might  be  rendered  by  these  workers  in  spreading  educational 
propaganda  where  it  was  most  needed,  namely,  in  the 
families  of  those  who  have  already  suffered  a  mental  break- 
down. 

According  to  the  Thirtieth  Annual  Report  of  the  State 
Hospital  Commission,  the  number  of  patients  on  parole  on 
June  30,  1918,  was  1,880;^  this  does  not  of  course  include 
those  whose  parole  period  of  six  months  had  expired. 
For  the  large  number  of  patients  technically  considered  as 
being  out  on  parole  there  were  only  thirteen  social  workers 
in  the  service  of  the  state,  for  whose  salaries  and  main- 
tenance^— the  only  two  items  in  the  after-care  budget — less 
than  $20,000  was  spent,  out  of  a  total  annual  budget  of  over 
$8,000,000.  The  actual  accomplishment  of  this  small  body 
of  workers  was  as  follows:  3,418  visits  to  paroled  patients, 

1  S.  H.  C,  30th  A.  R.,  p.  238. 


28 1 ]        STATE  HOSPITAL  CARE  AND  TREATMENT  139 

(an  average  of  less  than  two  visits  to  each  patient  on 
parole)  ;  727  visits  to  other  patients  outside  the  hospital ; 
1,841  other  visits  on  behalf  of  patients,  and  245  visits  in 
behalf  of  preventive  cases.  Situations  were  obtained  for  132 
patients  from  the  hospital  and  for  eleven  preventive  cases/ 
More  recently  arrangements  have  been  made  by  the  State 
Hospital  Commission  to  provide  one  after-care  worker  for 
every  100  patients  on  parole.  Apropos  of  this  welcome 
addition  to  the  stafif,  it  is  of  interest  to  note  that  the  social 
service  department  of  the  Boston  Psychopathic  Hospital 
does  not  assign  more  than  20  or  25  patients  to  each  worker. 

There  is  no  intention  to  disparage  the  good  work  of  the 
follow-up  staff  of  the  state  hospitals ;  it  is  desired,  rather,  to 
point  out  its  inadequacy.  The  whole  situation  regarding 
this  particular  phase  of  the  problem  was  well  summarized  by 
one  of  these  workers  when  she  stated  that  she  hardly  had 
the  time  to  keep  track  of  the  names  of  those  discharged  and 
paroled,  much  less  to  serve  them.  This  is  probably  a  some- 
what extreme  statement,  though  it  reflects  the  state  of  mind 
of  the  follow-up  agents  who  are  serving  the  state  in  the 
different  hospitals  as  best  they  can  considering  the  handicaps 
under  which  they  labor. 

(c)  Need  for  Follozv-Up  of  Jennsh  Patients.  Table  25 
indicates  that  63  Jewish  patients  were  discharged  as  re- 
covered from  the  Central  Islip  and  Manhattan  State  Hos- 
pitals, that  201  were  paroled  as  much  improved  and  im- 
proved, and  that  2 1  were  taken  home  by  relatives  in  an  un- 
improved condition.  This  makes  a  total  of  285  patients' 
who  left  these  institutions  during  the  year  to  return  to 
their  homes  and  previous  environment,  with  but  very  little, 
if  any,  supervision  and  follow-up  work.  If  action  on  the 
part  of  the  state  in  appropriating  sufficient  funds  for  the 

1  S.  H.  C,  30tih  A.  R.,  p.  237. 


I40     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [282 

establishment  of  large  and  well  organized  social  service 
staffs  in  the  several  state  hospitals  is  as  slow  in  materializ- 
ing as  it  has  been  heretofore,  the  question  arises  as  to 
wheither  it  would  not  bes  advisable  that  some  properly 
officered  and  equipped  Jewish  agency  assist  the  state  in  fol- 
lowing up  and  serving  these  patients,  all  o^f  whom  are  re- 
sidents of  the  City  of  New  York.  A  further  alternative 
presents  itself,  namely,  that  some  mental  hygiene  agency 
already  functioning  among  Jewish  patients,  or  one  to  be 
organized  on  a  much  larger  scale,  be  requested  by  the  state 
hospital  authorities  to  take  over  the  work  of  rendering  social 
service  to  the  Jewish  discharges.  Some  arrangement  might 
be  perfected  whereby  Jewish  social  workers  and  psychia- 
trists who  understand  the  unique  Jewish  psychology  could 
assist  the  state  social  workers  and  augment  the  service  and 
assistance  now  being  rendered. 

The  entire  problem  of  after-care  work  among  Jewish 
patients  is  one  that  should  and  must  in  the  near  future  be 
brought  to  the  serious  attention  both  of  the  state  authorities 
charged  with  the  proper  care  of  the  insane,  and  of  repre- 
sentatives of  Jewish  organizations  and  agencies  prepared  to 
render  this  particular  kind  of  service.  In  order  that  the  ab- 
normally high  readmission  rate  prevalent  among  Jewish 
patients  of  state  hospitals  be  materially  reduced  through 
timely  and  adequate  mental  hygiene  service,  some  such 
action  is  imperative. 

XIII.    DEATHS  IN   STATE   HOSPITALS 

(a)  Death  Rates  of  Jewish  Patients.  Those  who  are 
engaged  in  some  form  of  service  in  the  psychopathic  wards 
of  general  hospitals  to  which  insane  or  alleged  insane  per- 
sons are  brought  prior  to  their  commitment,  are  frequently 
asked  by  the  friends  and  relatives  of  these  patients  what  the 
possibilities  are  for  the  recovery  of  committed  cases.     The 


283]        STATE  HOSPITAL  CARE  AND  TREATMENT  141 

facts  regarding  the  rate  of  discharges  and  recoveries  have 
already  been  noted.  Table  24  shows  the  number  of  patients 
who  were  otherwise  disposed  of,  particularly  those  who 
died  in  the  institutions.  Of  the  total  of  784  admissions 
there  were  107  deaths,  a  death  rate  equivalent  to  13.6  per 
cent  of  the  admissions;  of  436  males  admitted  during  the 
year,  67  or  15.3  per  cent  died,  and  of  348  females  admitted 
in  the  same  period,  40  or  11.5  per  cent  died.  It  is  at  the 
present  time  difficult  to  draw  any  valid  comparisons  between 
the  death  rate  for  Jewish  admissions  and  for  the  total  ad- 
missions to  the  several  state  hospitals,  this  being  altogether 
due  to  the  fact  that  the  statistics  prepared  for  all  the  patients 
are  based  not  upon  the  admissions  for  the  given  year,  but 
upon  the  total  number  of  patients  under  treatment  during 
the  year.  Thus,  in  19 18,  the  death  rate  per  1,000  patients 
under  treatment  excluding  transfers,  which  are  compara- 
tively few  in  number,  was  85.5;  the  male  death  rate  was 
98.9,  and  the  female  rate  73.5.  The  one  point  of  com- 
parison is  the  higher  death  rate  indicated  for  males  in  both 
groups  of  figures. 

(b)  Reasons  for  Increasing  Death  Rates.  Somewhat 
debatable  ground  is  entered  when  considering  what  signi- 
ficance is  to  be  attached  to  the  fact  that  the  death  rate  per 
1,000  patients  under  treatment  for  all  the  hospitals  has 
been  slowly  but  definitely  increasing  from  year  to  year,  a 
condition  found  to  exist  ever  since  accurate  statistics  bear- 
ing on  this  phase  of  hospital  care  for  the  insane  have  been 
kept.  In  the  year  1897  the  total  rate,  that  is,  including 
males  and  females,  was  66.0  per  1,000  patients  under  treat- 
ment; in  19 1 7  it  had  increased  to  88.8,  with  a  somewhat 
lower  rate  for  1918,  namely  85.5.  The  irrefutable  fact  is 
that  the  death  rate  has  been  increasing  though  the  reasons 
Iherefor  are  not  so  obvious.  The  increasing  tendency  to 
send  cases  of  acute  mental  illness  to  state  hospitals  has 


142     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [284 

probably  contributed  to  this  condition.  The  ability  in  re- 
cent years  more  readily  and  accurately  to  diagnose  cases  of 
general  paralysis,  as  well  as  other  psychoses  with  high  death 
rates,  has  resulted  in  the  commitment  of  such  cases  to  state 
hospitals.  For  instance,  the  highest  death  rates  per  1,000 
patients  under  treatment  were  found  among  patients  suffer- 
ing with  general  paralysis,  the  rate  in  191 8  having  been 
352.8;  for  cerebral  arteriosclerosis  the  death  rate  was  340.2' 
during  the  same  year.  Furthermore,  up  to  the  last  decade 
oi  the  nineteenth  century  many  cases  of  senile  psychosisi 
were  housed  in  county  institutions,  whereas  at  present  all 
such  cases  as  reach  public  institutions  are  committed  to 
state  hospitals.  When  it  is  realized  that  for  cases  of  senile 
psychosis  the  death  rate  per  1,000  patients  under  treatment 
in  a  given  year,  as  in  1918,  was  297.2,  it  is  at  once  seen 
why  the  general  death  rate  has  increased  so  much  in  more 
recent  years.  The  factors  just  mentioned  have  undoubtedly 
been  largely  responsible  for  the  increased  death  rate,  though 
the  sum  total  of  their  effect  upon  the  statistical  averages 
must  to  some  extent,  at  least,  be  neutralized  by  the  better  and 
higher  standard  of  care  accorded  to  state  hospital  patients 
during  the  past  twenty  or  more  years,  with  the  resultant  in- 
crease in  the  length  of  life  of  large  numbers  of  patients. 

The  following  table  shows  that  those  who  died  suffering 
from  general  paralysis  were  43  in  number,  equivalent  to 
40. 1  per  cent  of  the  total  -number  of  deaths ;  ^  the  deaths  from 
senile  psychosis  numbered  20,  or  18.6  per  cent  of  the  total 
deaths. 

'Dublin.  Louis  1.,' Mortality  Statistics  of  Insured  Wage-Earners  and 
their  Families,  1919,  pp.  271-272,  presents  a  discussion  of  death  rates 
among  a  large  number  of  insured  persons  where  the  cause  of  death 
was  general  paralysis. 


285]        STATE  HOSPITAL  CARE  AND  TREATMENT  143 

Table  26.     Diagnosis  of  Patients  who  Died  in  State  Hospitals 


Diagnosis. 


General  Paralysis 

Senile  Psychosis 

Arteriosclerosis 

Manic  Depressive 

Dementia  Praecox 

Epileptic  Psychosis 

Constitutionally  Psy.  Inf. . 
Involutional  Melancholia 
Infection  Exhaustion  Psy, 
Intoxication  Psychosis  . . . 

Totals 


Central  Islip. 


18 


13 


Manhattan. 


30 
4 
2 
6 
3 
3 


49 


4 
10 
2 
4 
5 


27 


Total. 


37 


67 


6 
12 

4 
10 

5 

I 
I 
I 


40 


The  total  number  of  cases  admitted  during  the  year  and 
diagnosed  as  afflicted  with  general  paralysis  was  99,  out  of 
which  as  already  noted,  43  died  within  the  year.  This  gives 
a  death  rate  of  approximately  400  out  of  1,000  such  patients 
admitted  within  the  year,  a  figure  somewhat  higher  than  the 
death  rate  for  all  the  patients  similarly  diagnosed.  The 
death  rate  for  the  senile  cases  was  about  the  same  as  the 
rate  for  all  the  cases  classified  under  this  diagnosis. 

XIV.    LENGTH  OF  STAY  IN  THE  HOSPITALS 

Reference  has  already  been  made  in  explanation  of  Table 
25  to  the  difference  between  Central  Islip  and  Manhattan 
State  Hospitals  in  the  ratio  of  patients  signed  out  asi 
"  recovered  " ;  in  analyzing  the  above  figures  the  statements 
referred  to  should  be  taken  into  consideration.  This  table 
furthermore  emphasizes  the  facts  noted  in  Qiapter  II  re- 
garding the  recovery  rate  of  the  different  psychoses,  parti- 


144     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [286 
Table  27.    Duration  of  Hospital  Life  of  Recovered  Cases 


M.  D.  I. 

Cons. 
Inf. 

No. 

4 

4 

8 

Para, 

Cond. 

No. 

I 

I 

D.  P. 
Kat. 

All 
Others. 

Totals, 

No. 

2 

21 
II 

No. 

I 
I 

2 

No, 

No, 

2 
24 
26 
II 

63 

Per  cent. 

Less  than  i  month 

I  to    3  months 

4  to    7  months 

8  to  II  months 

3 
3 

31 
38.1 
413 
17.5 

Totals 

49 

100  0 

cularly  the  comparative!}^  higher  rate  among  cases  of  manic 
depressive  insanity.  It  is  seen  that  nearly  all  patients  who 
recovered  had  suffered  with  manic  depressive  insanity;  the 
eight  cases  included  as  cases  of  constitutional  inferiority 
suffered  depressions  similar  in  nature  to  those  usually  in- 
cluded under  the  category  of  manic  depressive  insanity,  de- 
pressed type,  the  depression  coming  in  addition  to  the  con- 
stitutional ailment.  Recoveries  of  cases  of  dementia  prae- 
cox,  katatonic  type,  are  very  rare,  and  some  authorities  are 
inclined  to  the  opinion  that  often  such  cases  as  are  recorded 
as  having  recovered  have  been  inaccurately  diagnosed  in  the 
hospitals  from  which  they  have  been  discharged  in  a  re- 
covered or  even  improved  condition.  Their  contention  is 
that  the  patients  thus  diagnosed  were  suffering  from  some 
condition  of  stupor  and  were  not  true  cases  of  katatonic 
dementia  praecox.  Be  that  as  it  may,  the  niunber  of  re- 
corded recoveries  is  so^  small  as  tO'  be  almost  negligible/ 

Table  28  serves  the  double  purpose  of  indicating  the  diag- 
noses of  the  improved  and  much  improved  cases,  and  of 
showing  the  duration  of  hospital  life  of  the  patients  classi- 


*  de  Fursac  and  Rosanoflf,  Manual  of  Psychiatry,  p.  262. 


287] 


STATE  HOSPITAL  CARE  AND  TREATMENT 


145 


Table  28.    Duration  of  Hospital  Life  of  Improved  and  much 
Improved  Cases 


Q 

No. 

14 

36 

37 

7 

94 

Q 
No. 

I 

14 

27 

13 

55 

Ph' 

d 
No. 

4 
I 

I 

6 

Ph 

C 
<u 

No. 

I 
2 
2 

I 

6 

< 
No. 

I 
2 
2 

I 

6 

w 

No. 

2 
4 

7 

IS' 

a 

No. 

3 
3 

6 

<u 

so 

< 
No. 

3 
6 

9 
3 

21 

Totals. 

No. 

22 

71 

82 
26 

201 

Per 
cent. 

Less  than    i  month 

10.9 

35-5 
40.8 
12.8 

Totals 

100,0 

fied  in  these  two  groups.  There  were  94  cases  of  manic  de- 
pressive insanity  paroled,  tO'  which  should  be  added  the  49 
cases  of  the  same  diagnosis  included  in  Table  27  as  re- 
covered, making  a  total  of  143  patients  diagnosed  as  manic 
depressives  discharged  as  recovered  or  improved.  From 
Table  5  it  is  seen  that  294  such  cases  were  originally  com- 
mitted to  state  hospitals,  out  of  which  143  or  48.6  per  cent 
were  discharged  as  recovered  or  in  an  improved  condition. 
Two  hundred  and  seventy-nine  cases  o^f  dementia  praecox 
were  committed  to  state  hospitals ;  of  this  number  two  pre- 
sumably recovered  and  55  were  discharged  as  improved, 
these  57  cases  being  equivalent  to  20.4  per  cent  of  the  total 
commitments.  Of  the  cases  of  general  paralysis,  senile 
psychosis  and  cerebral  arteriosclerosis,  the  three  groups  in 
which  the  highest  proportion  of  deaths  occur,  there  were,  as 
might  properly  be  expected,  no  recoveries  at  all,  while  each 
group  indicated  improved  conditions  in  six  cases.  There 
were  seven  patients  discharged  as  improved  who  had  been 
diagnosed  as  suffering  from  epileptic  psychosis,  and  six 
diagnosed  as  cases  of  constitutional  psychopathic  inferiority 
were  similarly  discharged. 


146     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [288 

Regarding  the  duration  of  hospital  Hfe  of  improved  and 
much  improved  discharges,  it  is  to  be  noted  from  Table  28 
that  10.9  per  cent  of  the  discharges  took  place  within  the 
first  month  of  hospital  residence;  35.5  per  cent  were  sent 
home  in  from  one  to  three  months,  40.8  per  cent  were  de- 
tained from  four  to  seven  months,  and  12.8  per  cent  from 
eight  to  eleven  months.  The  indications  therefore  are  that 
it  should  take  from  one  toi  seven  months  of  institutional 
life  before  approximately  80  per  cent  of  the  patients  dis- 
charged as  in  an  improved  condition  will  be  permitted  to 
leave  the  hospitals  on  parole.  With  better  hospital  con- 
ditions obtaining  in  the  state  institutions,  with  less  over- 
crowding, and  a  higher  ratio  of  physicians  and  nurses  to 
the  number  of  patients  under  treatment,  the  duration  of 
hospital  residence  for  presumably  recoverable  cases  would 
undoubtedly  be  shortened,  with  a  resultant  decrease  in  the 
general  cost  of  operation  and  maintenance  of  the  hospitals. 
Even  if  the  increased  cost  of  managing  the  state  hospitals 
after  making  these  changes  went  far  tO'  offset  the  decrease 
in  cost  of  maintenance  as  a  result  of  earlier  discharges,  yet 
the  added  expenditure  would  be  sufficiently  justified  by  the 
fact  that  patients  could  be  returned  to  normal  environments 
and  to  their  families  and  friends  weeks  if  not  months 
sooner  than  at  present. 

It  is  noticed  from  Table  29  that  the  majority  of  the  deaths 
occured  within  four  months  of  admission  to  the  state  hos- 
pitals and  that  86.9  per  cent  died  in  less  than  eight  months. 
Those  showing  the  shortest  length  of  life  within  the  institu- 
tions were  the  cases  oi  general  paralysis,  about  75  per  cent 
of  which  died  in  less  than  four  months  of  institutional  re- 
sidence. Coupled  with  the  fact  that  43.4  per  cent  of  the 
total  number  of  admissions  of  paretics  died  within  the  year, 
it  is  evident  that  the  menace  of  general  paralysis  to  the 
duration  of  life  is  exceedingly  threatening.     The  high  rate 


289] 


STATE  HOSPITAL  CARE  AND  TREATMENT 


147 


Table  29.    Duration  of  Hospital  Life  of  Patients  Dying  in 
State  Hospitals 


6 

No. 

13 
19 

7 
4 

43 

Ph 

a 

<u 

in 
No. 

3 
7 

1 

3 
20 

Q 
S 

No. 

8 
4 
3 
3 

18 

Q 
No. 

2 
2 
3 
3 

10 

1) 

1-1 

No. 
2 

4 
I 

7 

-I' 
w 

No. 

I 

3 

I 

5 

in 

1-. 

No. 

3 
I 

4 

Totals, 

No. 

29 

39 
25 

14 
107 

Per 
cent. 

27.1 
36.4 
23-4 
I3-I 

8  to  1 1  months 

Totals 

100,0 

of  early  deaths  from  manic  depressive  insanity  is  due  to 
the  fact  that  a  certain  proportion  of  these  patients  is  rather 
prone  to  an  early  demise  as  a  result  of  physical  exhaustion 
following  the  occasional  restraint  into  which  these  patients 
are  put.  The  tendency  in  the  New  York  State  Hospitals,  as 
well  as  in  all  modem  and  up-to-date  similar  institutions,  has 
been  to  reduce  the  number  of  patients  put  into  physical  re- 
straint during  temporary  or  prolonged  periods  of  excite- 
ment. Nevertheless,  overcrowding  and  the  inadequacy  of 
the  hospital  staffs  for  the  large  number  of  patients  under 
treatment  occasionally  necessitate  the  violation  of  a  more 
recent  conception  of  the  methods  to  be  employed  under 
such  circumstances — the  use  of  hydrotherapeutic  apparatus, 
such  as  the  continuous  bath,  in  the  place  of  restrainingt 
sheets  or  bandages,  which  are  but  vestiges  of  the  chain  and 
dungeon  period  of  the  treatment  of  the  insane. 

This  is  but  another  indication  of  the  pressing  need  for 
changes  or  reforms  in  our  current  methods  of  treating  and 
caring  for  the  insane,  particularly  the  Jewish  insane. 
Several  questions  have  already  been  raised  as  to  the  ad- 
visability of  continuing  the  present  procedure  of  indiscrim- 


148     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [290 

inately  and  regularly  committing  all  indigent  and  semi-in- 
digent Jewish  patients,  recoverable  and  otherwise,  to  state 
institutions  in  which  they  apparently  do  not  progress  along 
the  road  to  recovery  as  well  as  do  some  other  groups  of 
patients.  The  evident  and  only  conclusions  that  can  be 
drawn  from  these  facts  are,  either  reforms  must  come  from 
within,  that  is,  from  the  state  hospitals  themselves  and 
through  the  State  Hospital  Commission,  or  private  organ- 
izations and  agencies  must  enter  the  fie]d  and  supplement  or 
take  over  some  of  the  work  of  the  state  institutions,  with 
particular  reference  to  so-called  recoverable  cases;  a  third 
alternative  that  suggests  itself  is,  that  there  might  possibly 
be  effected  a  combination  of  the  first  two  recommendations. 


CHAPTER  IV 
A  Social  Survey  of  786  Admissions  to  State  Hospitals 

I,  introduction 

In  the  preceding  chapter  the  attempt  was  made  to  point 
out  the  shortcomings  of  the  state  hospital  system  insofar 
as  care  and  treatment  in  the  hospitals  themselves  are  con- 
cerned. As  has  by  now  become  evident,  this  study  aims  toi 
consider  the  patients  from  all  angles,  including  the  care  ac- 
corded in  the  place  of  temporary  confinement,  particularly 
in  Bellevue  Hospital ;  the  care  and  treatment  in  the  institu- 
tions to  which  they  are  committed,  i.  e.,  the  state  hospitals; 
the  condition  and  progress  of  the  patients  discharged  from 
the  state  hospitals;  and  the  work  of  the  after-care  or 
parole  agents  of  these  hospitals.  Before  turning  to  a 
consideration  of  the  main  topics  to  be  discussed  in  thig 
chapter,  it  might  be  well  to  give  thought  tO'  a  number  of 
social  facts  which  this  study  has  developed  regarding  the 
insane.  In  the  second  chapter  a  table  of  the  marital  con- 
dition of  the  patients  admitted  to  Bellevue  Hospital,  psycho- 
pathic wards,  was  presented  (Table  10).  From  this  table 
it  was  seen  that  out  of  a  total  of  1,127  patients,  596  or  52.9 
per  cent  were  single,  435  or  39.6  per  cent  were  married; 
and  of  the  males,  25  patients  were  widowed  and  8  divorced; 
whereas  of  the  females,  53  patients  were  widowed  and  10 
divorced.  These  facts  in  themselves  do  not  throw  sufficient 
light  upon  the  subject  of  social  needs  or  upon  the  possibili- 
ties for  service  among  the  patients,  discharged  or  other- 
wise, or  among  their  families. 

291]  149 


150     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [292 

II.    THE  FAMILY  OF  THE  INSANE  PATIENTS 

In  his  volume  on  "  The  Family  and  Social  Work,"  Dr. 
Edward  T.  Devine  points  out  that  the  methods  and  policies 
of  scientifically  organized  charitable  relief  have  been  adopted 
or  rejected  according  to  their  profitable  effect  on  family 
standards,  and  that  it  has  become  an  axiom  that  each  in- 
dividual who  is  in  need  of  assistance  must  be  considered  in 
his  family  setting  if  he  is  to  be  helped  effectively,^  While 
this  opinion  emphasizes  relief  work,  it  is  equally  applicable 
to  all  phases  of  social  work  worthy  the  name.  How  true 
this  is  in  cases  of  insanity  is  only  too  evident,  for  in  but  few 
other  forms  of  social  distress  is  the  family  more  thoroughly 
upset  and  in  need  of  proper  advice  and  guidance.  The 
question  of  the  hereditary  nature  of  insanity  has  a  very  dis- 
turbing effect  on  the  relatives  and  immediate  members  of 
the  family  of  an  insane  person  when  they  learn  that  one  of 
their  own  flesh  and  blood  has  been  declared  insane. 

There  were,  as  has  been  previously  noted,  786  patients 
admitted  to  the  Manhattan  and  Central  Islip  State  Hospitals 
out  of  the  total  of  1,127  admissions  to  the  psychopathic 
wards  of  Bellevue  Hospital.  In  evaluating  the  services 
being  rendered  a  community  by  its  social  agencies  it  is  ad- 
visable, in  justice  to  the  institutions  as  well  as  to  the  public, 
that  the  efforts  expended  in  ameliorating  social  conditions! 
be  given  a  fair  trial.  A  prime  factor  in  such  procedure 
must  necessarily  be  the  question  of  the  time  permitted  to 
elapse  prior  to  the  passing  of  judgment.  It  goes  without 
saying  that  the  problem  must  be  very  carefully  followed  out 
and  studied  during  this  time.  In  this  connection,  it  has  been 
deemed  advisable  to  begin  to  survey  the  results  of  the  work 
of  the  state  hospitals  in  treating,  and  when  possible  curing 
patients,  one  year  after  the  admission  of  a  particular  group 

1  Devine,  Edward  T.,  The  Family  and  Social  Work,  p.  32. 


293]      PURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       151 

to  the  institutions.  That  is,  patients  admitted  to  a  state 
hospital  on  a  given  date  have  not  been  considered  subjects 
for  study  in  the  sense  outhned  in  this  chapter  until  twelve 
months  later. 

The  movement  of  patients,  including  death  rates,  was 
discussed  at  length  in  the  preceding  chapter  and  in  this 
connection  only  facts  essential  toi  a  proper  understanding  of 
the  problem  as  a  whole  in  some  of  its  other  aspects  will  be 
considered  in  the  major  portion  of  the  pages  that  follow. 
Since  this  part  of  the  study  co'ncerns  itself  more  particularly 
with  the  social  phase  of  the  subject,  and  the  aim  is  tO'  obtain 
facts  and  arrive  at  conclusions  relative  to  the  social  con- 
ditions of  the  patients  and  their  families,  using  the  term 
"  social  conditions  "  in  its  broadest  sense,  the  total  or  786 
patients  have  been  divided  into  four  categories.  These  are 
(a)  those  still  in  the  hospitals  at  the  end  of  one  year — mostly 
single  persons — who  have  no  dependents  and  no  family  re- 
sponsibilities;  (b)  those  still  in  the  state  hospitals  at  the 
end  of  one  year,  who,  prior  to  their  admission,  had  family 
responsibilities ;  (c)  those  who  died  in  the  hospitals,  whether 
or  not  they  left  minor  children  or  other  dependents ;  and  (d) 
those  discharged  from  the  hospitals  within  a  year  after  ad- 
mission. 

III.    SINGLE  PERSONS  WITHOUT  DEPENDENTS,  IN  STATE 
HOSPITALS  FOR  ONE  YEAR 

Some  consideration  has  already  been  given  to  the  very 
large  loss,  economic  and  otherwise,  sustained  by  society  in 
the  withdrawal  from  industry  and  gainful  occupation  of 
thousands  of  young  persons  whom  it  has  been  found  neces- 
sary to  commit  and  to  detain  in  hospitals  for  the  insane. 
Many  of  these  patients  are  doomed  to  remain  in  the  custody 
and  under  the  supervision  of  the  state  for  many  years,  if 
not  for  the  remainder  of  their  lives.     Referring  especially 


152     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [294 

to  the  group  of  786  cases  already  spoken  of,  it  is  interesting 
to  note  that  out  of  this  number  there  remained  in  the 
institutions  at  the  end  of  one  year  244  single  persons  without 
dependents.  These  were  mainly  yoimg  persons  with  a 
history  of  irregularity  of  employment  and  with  only  inter- 
mittent periods  of  gainful  occupation  to  their  credit.  This 
may  be  ascribed  to  the  fact  that  of  the  244  single  persons, 
151  or  62  per  cent  had  been  diagnosed  as  suffering  from 
one  of  the  forms  of  dementia  praecox,  which,  as  has  pre- 
viously been  pointed  out,  is  at  the  present  time  considered 
as  being  largely  chronic  in  nature.  Among  the  remaining 
number  of  cases  only  61  or  25  per  cent  represented  patients 
diagnosed  as  cases  of  manic  depressive  insanity,  usually 
thought  of  as  a  recoverable  form  of  insanity. 

Little  need  or  can  be  said  pertaining  to  the  social  con- 
ditions of  these  patients  and  their  relatives.  The  former 
will  remain  in  the  hospitals  until  the  doctors  feel  that  they 
have  sufficiently  improved  mentally  to  render  it  safe  and 
advisable  to  give  them  the  opportunity  of  attempting  to  ad- 
just themselves  in  what  we  call  a  normal  environment. 
The  state  and  society  are  at  the  present  time  doing  little  to 
aid  them  in  the  stressing  process  of  readjustment  to  difficult 
living  and  working  conditions. 

Under  ordinary  circumstances  it  would  be  fair  to  assume 
that  in  nearly  every  case  there  would  be  relatives  and  f riendsl 
ready  and  willing,  as  well  as  prepared,  to  give  the  paroled 
patient  every  help  and  chance  to  redeem  himself  mentally 
and  physically,  and  even  socially  and  economically.  How- 
ever, many  of  these  young  people  came  to  this  country  with 
the  aim  of  bettering  themselves,  and  in  the  attempt  over- 
worked and  broke  down  after  giving  the  best  that  was  in 
them  to  the  industries  in  which  they  were  employed.  Hav- 
ing arrived  here  alone,  they  usually  had  no  one  to  turn  to 
upon  discharge  from  the  hospitals.     This  resulted  in  the 


295]      PURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       153 

retardation  of  their  full  recovery  and  in  increased  dif- 
ficulties in  readjusting  themselves  to  alien  conditions. 
This  particular  phase  of  the  subject  will  be  more  fully  dis- 
cussed in  the  follov^ing  pages,  but  it  may  be  apropos  to 
mention  at  this  point  that  there  are  organizations  in  Newi 
York  that  provide  positions  and  other  requisites  to  dis- 
charged prisoners,  persons  who  have  violated  the  laws  of 
the  state;  and  yet,  for  those  who  have  fallen  by  the  way- 
side as  a  result  of  illness,  little  if  anything  is  attempted  in 
the  way  of  real  help  and  assistance. 

(a)  Value  of  Visits  to  Patients.  The  patients  remain- 
ing in  state  hospitals  and  having  relatives  are  somewhat 
better  off  because  of  the  greater  attention  they  receive 
through  the  agency  of  regular  visits  paid  them  and  the 
delicacies  and  other  things  brought  to  them.  These  are 
seemingly  small  matters,  but  to  sensitive  individuals  who 
still  retain  many  of  their  faculties,  though  they  may  be  in 
depressed  or  elated  or  even  stuporous  conditions  for  greater 
or  lesser  periods  of  time,  the  modicum  of  interest  displayed 
by  visiting  relatives  and  friends  helps  in  the  improvement 
of  their  mental  condition.  Foster  relatives  in  the  guise  of 
social  workers  assigned  to  the  state  hospitals  for  work  on 
the  wards  would  go  a  long  way  towards  breaking  the  ter- 
rible monotony  of  life  in  a  state  hospital,  and  thus  help  in 
the  earlier  improvement  of  improvable  and  recoverable 
cases.  A  state  hospital  superintendent  once  remarked  that 
if  a  small  group  of  normal  individuals  were  compelled  to 
remain  within  a  circumscribed  area,  as  in  a  ward,  for  any 
length  of  time,  several  if  not  all  these  persons  would  in  a 
relatively  short  time  begin  to  feel  and  believe  that  one  or 
more  of  the  other  persons  within  the  confined  limits  of  the 
four  walls  had  developed  an  antagonism  and  even  hatred 
towards  the  others.  This  would  resolve  itself  eventually 
into  ideas  of  persecution  and  actual  psychoses.     If  such  be 


154     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [296 

the  case  even  to  a  limited  extent  among  normal  individuals, 
how  much  more  liable  to  mental  deterioration  are  persons 
already  adjudged  insane  and  confined  in  overcrowded  hos- 
pitals and  wards  month  after  month  and  year  upon  year. 

(b)  Attitude  of  Patients'  Relatives  toward  State  Hos- 
pitals. Many  visits  to  the  homes  of  relatives  of  patients 
committed  to  state  hospitals,  even  where  such  relatives  have 
not  been  directly  dependent  upon  the  patients  for  either  total 
or  even  partial  support,  have  shown  the  forcefulness  with 
which  the  relatives  are  impressed  with  the  fact  that,  at  least 
to  their  way  of  thinking,  well-nigh  nothing  is  being  done  to 
hasten  the  recovery'  oi  the  persons  detained  in  the  hospitals 
by  the  state.  The  result  is  that  the  next  of  kin  and  friends 
are  constantly  insisting  upon  the  discharge  to  their  custody 
of  patients  who  may  be  a  menace  tO'  themselves  and  to 
others,  and  would  certainly  be  a  definite  burden  to  keep  at 
home.  They  feel  that  they  can  do  more  for  the  afflicted 
members  of  their  families  than  the  hospitals  accomplish. 

It  is  quite  useless  and  of  no  avail  to  discuss  with  these 
relatives  the  fact,  for  instance,  that  the  hospital  superintend- 
ents and  physicians  would  do  more  to  hasten  the  improve- 
ment Oif  patients  if  they  only  had  the  necessary  funds  which 
which  to  provide  better  accommodations,  or  to  hire  a  higher 
grade  of  attendants  and  a  larger  proportion  of  trained 
nurses.  It  is  likewise  inadvisable,  as  a  rule,  to  tell  them, 
even  if  one  always  had  the  heart  to  do  so,  that  their  dear 
ones  are  suffering  from  a  form  of  insanity  which  has  to 
this  day  baffled  the  best  minds  in  the  field  of  psychiatry; 
and  that,  as  far  as  one  can  truthfully  say,  the  patients  will 
probably  never  be  well  mentally.  The  only  thing  that  can 
be  done  is  to  point  out  to  relatives  and  friends  that  the 
doctors  and  nurses  are  doing  all  in  their  power  to  hasten 
the  recovery  of  all  patients,  and  to  advise  against  the 
attempted  withdrawal  from  the  institutions  of  patients  of 


297]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       155 

known  suicidal  or  homicidal  or  probable  perverted  tenden- 
cies. 

IV.    MARRIED,    WIDOWED    AND    DIVORCED    PERSONS,    WITHOUT 
DEPENDENTS^  REMAINING  IN  STATE  HOSPITALS 

As  might  naturally  be  expected,  there  were  smaller  num- 
bers oi  married,  widowed  and  divorced  persons  without  de- 
pendents detained  in  the  hospitals  at  the  end  of  one  year  of 
institutional  residence  than  there  were  single  persons  placed 
in  this  category.  The  statements  already  made  regarding 
unmarried  people  apply  with  equal  force  to  the  three  groups 
now  being  considered.  In  many  instances,  the  desire  to 
obtain  the  early  discharge  of  a  husband  or  wife,  father  or 
mother,  is  even  more  determined.  The  departure  from  the 
home  oif  such,  a  person  has  in  numerous  cases  resulted  in 
the  breaking  up  of  the  household  and  the  scattering  of  the 
remaining  members.  As  a  rule,  it  is  only  after  prolonged 
deliberation  on  the  part  of  immediate  relatives  that  such 
patients  are  committed,  this  usually  occurring  when  it  is 
found  that  the  entire  life  of  the  family  is  disturbed  by  the 
peculiar  habits  and  behavior  of  those  who  have  become 
mentally  ill.^  Families  of  very  meagre  income  have  put 
themselves  greatly  in  debt  so  as  to  send  such  persons  to 
high-priced  private  sanatoria,  only  to  find  to  their  dismay 
that  at  the  end  of  a  few  weeks  all  the  resources  are  ex- 
hausted and  the  patients  very  little  improved,  if  improve- 
ment there  has  been.  The  result  has  been  that  these  patients 
are  finally  committed  to  a  state  hospital. 

V.    SOCIAL  STATUS  OF  PATIENTS  WHO  DIED  IN  STATE  HOS- 
PITALS 

The  ratio  of  the  deaths  to  the  total  admissions  has  already 

1  Henderson,  Charles  R.,  Dependents,  Defectives  and  Delinquents, 
1909,  p.  184. 


156     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [298- 

been  indicated,  and  the  division  into  sexes  has  Hkewise  been 
dwelt  upon  (Table  24).  For  purposes  of  convenience  these 
figures  are  repeated;  of  the  total  of  784  admissions  to  state 
hospitals  there  were  107  deaths  during  the  year,  equivalent 
to  a  death  rate  of  13.6  per  cent.  There  were  436  males 
admitted,  of  whom  67  or  15.3  per  cent  died,  whereas  of  the 
348  females  admitted,  40  or  1 1.5  per  cent  died. 

(a)  Single.  A  further  classification  of  these  patients  has 
shown  that  of  the  single  persons  who  died,  17  were  males 
and  9  females.  From  the  point  of  view  of  their  relation  to 
their  next  of  kin  and  the  bearing  such  deaths  had  upon 
the  immediate  and  future  social  status  of  the  families  of 
which  they  were  a  part,  it  has  been  found  that  these 
patients  fall  into  five  groups.  The  first  group  comprises 
young  people  who  either  contributed  very  little  or  nothing^ 
to  the  family  income,  often  having  been  a  serious  burden 
and  drain  upon  the  financial  resources  of  the  family.  The 
imtimely  deaths  of  these  persons  did  not  in  any  case  ser- 
iously affect  the  status  of  the  family;  in  some  instances  the 
removal  of  the  hopelessly  insane  was  a  cause  of  positive  re- 
lief in  more  ways  than  one.  The  second  group  is  made  up 
of  workers  whose  loss  of  income  will  be  felt  by  the  family 
but  not  sufficiently  to  render  appeal  for  financial  assistance 
to  a  social  agency  necessary.  Such  families  readily  ad- 
justed themselves  to  the  lessened  income.  In  fact,  so  many 
of  these  patients  had  been  ill  for  varying  and  prolonged 
periods  of  time  that  while  they  were  periodically  engaged 
in  some  gainful  occupation,  nevertheless  they  represented  an 
economic  loss  both  from  the  point  of  view  of  society  as  a 
whole  and  of  their  own  families  in  particular.  In  the  third 
group  are  classed  persons  who  had  no  immediate  relatives 
in  this  countr}%  representing  almost  altogether  recent  im- 
migrants whose  deaths  could  not  materially  affect  the 
social  status  of  their   families   in  other  lands.     It  is,   of 


299]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       157 

course,  realized  that  famdlies  in  European  as  well  as  other 
lands  often  pool  their  savings  in  order  to  help  one  of  the 
more  able  members  of  the  group  to  migrate  to  "  the  land  of 
promise,"  hoping  thereby  to  profit  from  the  increased  earn- 
ings of  such  as  come  to  these  shores.  The  question  is 
whether  in  these  cases  loss  of  income  and  any  resultant  low- 
ering of  the  standard  of  living  can  be  properly  gauged,  as 
we  presumably  can  only  surmise  the  effects  of  the  death  of 
adult  wage-earners.  Furthermore,  from  the  point  of  view 
of  the  problem  here  in  this  state  and  country,  these  cases  are 
negligible  factors,  at  least  insofar  as  our  standards  are 
affected  and  the  welfare  of  future  citizens  involved.  Stress 
has  already  been  laid  upon  the  social  drain  incurred  through 
the  loss  of  efficiency  and  health  as  well  as  of  life  itself  by 
those  who  become  infected  with  syphilis  and  such  of  their 
number  who  eventually  develop  general  paralysis.  These 
constitute  the  fourth  group.  Oi  the  single  persons  dying 
of  this  disease,  none  bore  any  definite  family  responsibili- 
ties. They  were  largely  individuals  who  had  either  be- 
come alienated  or  otherwise  separated  from  their  families 
years  before  their  deaths  took  place  and  whose  loss  was  not 
seriously  felt  by  relatives,  except  perhaps  for  the  sympa- 
thetic reaction  exerted  upon  kith  and  kin.  The  last  group 
represents  deaths  of  single  persons  of  advanced  years  from 
senile  psychosis.  Such  deaths  would  naturally  be  expected 
to  affect  the  social  status  of  few,  if  any,  persons. 

(b)  Married.  It  is  interesting  to  note  that  married  per- 
sons dying  in  the  state  hospitals  contributed  62  out  of  107 
deaths;  of  these  41  were  males  and  21  females.  The  possible 
social  needs  to  be  uncovered  by  a  careful  study  of  familiesi 
of  wage-earners  in  which  either  the  father  or  mother  have 
died  would  necessitate  a  discussion  in  great  detail  of  al- 
most every  social  agency  operating  in  a  community, 
coupled  with  an  appraisal  of  the  efficiency  with  which  ser- 


158     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [300 

vice  has  been  rendered  in  the  comparatively  large  number  of 
cases  being  considered.  The  purpose  of  this  work  being 
rather  to  point  out  the  social  implications  of  the  problem  of 
insanity  as  a  w^hole,  and  not  to  limit  its  scope  to  a  study  of 
particular  cases  only,  it  is  obvious  that  the  aim  in  view  could 
not  be  realized  within  the  confines  of  a  single  volume  un- 
less some  necessary  limitations  were  set.  And  so,  instead 
of  considering  at  length  all  details  of  the  problems  found 
to  be  involved  in  the  cases  being  studied  under  this  heading, 
it  is  taken  for  granted  that  certain  factors  are  only  touched 
upon  and  it  is  left  tO'  the  reader  to  follow  out  in  greater 
detail  by  reference  to  standard  works  on  the  subject,  such 
particular  interests  as  may  be  awakened  by  a  perusal  of 
these  pages. 

(c)  Status  of  Family  Following  Death  of  Husband. 
Analysis  of  the  social  histories  of  the  married  persons  who 
died  in  the  state  hospitals  shows  that  they  fall  into  several 
classes.  Of  the  males  dying  there  were  those  who  left  be- 
hind  them : 

(a)  a  wife  and  wage-earning  adult  children. 

(b)  a  wife  of  advanced  years  taken  in  by  relatives  or 
aided  by  a  relief  organization. 

(c)  a  wife  and  minor  children,  all  aided  by  relatives. 

(d)  a  wife  and  minor  children  aided  by  a  relief  organiza- 

tion as  husband  and  father  was  not  a  citizen,  thereby 
disqualifying  children  from  receiving  a  pension. 

(e)  a  wife,  childless,  living  apart  from  husband  the 
latter  part  of  his  lifetime,  because  of  his  physical 
and  mental  condition. 

(f)  a  wife,  with  minor  children,  self-supporting,  be- 
cause of  a  small  business  operated  by  the  mother. 

(g)  a  wife,  childless,  working  and  self-supporting  for  a 
number  of  years  prior  to  death  of  husband. 


301  ]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       159 

(h)  a  wife  with  minor  children,  working  several  years 
prior  to  death  of  husband,  and  supporting  the  entire 
family, 
(i)  a  wife  and  minor  children,  latter  cared  for  by  re- 
latives while  mother  went  out  working,  even  during 
the  lifetime  of  husband, 
(j)   a  wife  and  children,  family  with  independent  meang 

and  in  comfortable  circumstances, 
(k)   a  wife  and  minor  children,  recipients  oi  a  pension, 

father  having  been  a  citizen. 
(1)   a  wife  in  a  state  hospital  and  children  all  adults, 
(m)   a  wife  and  children  in  Europe, 
(d)   Status    of    Family    Following    Death    of    Wife.     Ai 
consideration   of   the  cases   in  which   the   mother   of   the 
family  died  would  quite  naturally  be  expected  to»  indicate 
fewer  instances  in  which  financial  aid  or  assistance  wasi 
needed,  but  other  forms  of  social  service  had  to  be  called 
upon  to  meet  the  emergency  created  through  the  death  of 
the  mother  of  minor  children.     The  analysis  of  the  deaths 
among  married  females  shows  that  they  might  be  classified 
as  follows  from  the  point  of  view  of  social  need  discovered 
in  the  families : 

(a)  minor  children  cared  for  by  relatives  other  than  the 
father. 

(b)  husband  being  cared  for  by  adult  children,  patient 
having  died  at  an  advanced  age  leaving  no  depend- 
ents. 

(c)  husband  boarding  out  the  minor  children. 

(d)  husband  committing  children  to  an  orphan  asylum. 

(e)  husband  alone  remaining;  childless  marriage. 

( f )  husband  unable  properly  to  care  for  children  during 
illness  of  wife,  and  children  placed  with  relatives. 

(g)  husband  in  army  when  wife  died;  children  placed 
with  relatives  by  Home  Service  Section,  American 
Red  Cross. 


l6o     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [302 

It  is  of  course  realized  that  the  instances  above  enumerated 
in  regard  to  both  the  male  and  the  female  married  patients 
dying  in  the  institutions  do  not  exhaust  the  list  of  possible 
circumstances  in  which  the  families  might  have  been  left, 
but  they  do  represent  the  actual  conditions  in  which  a 
nimiber  of  families  were  found.  The  groups  under  study 
are  particularly  interesting  from  the  social  point  of  view 
because  they  represent  almost  entirely  persons  of  wage- 
earning  families  and  very  few,  if  any,  of  large  or  com- 
paratively large  business  or  other  holdings. 

VI.    SOCIAL  PROBLEMS  FOLLOWING  DEATH   OF  MARRIED 
PATIENTS 

Attention  has  already  been  paid  to  the  desirability  as  well 
as  to  the  necessity  of  considering  the  patients  from  the 
point  of  view  of  their  place  in  a  given  family,  if  con- 
structive work  is  to  be  done  for  the  patients  as  well  as  for 
those  related  to  them  by  ties  of  blood.  This  particular  part 
of  the  discussion  deals  with  patients  who  have  passed  be- 
yond all  possible  aid  and  relief,  and  have  left  behind  them 
heritages  which  are  not  always  social  assets.  In  his  volume 
on  the  Psychic  Treatment  of  Nervous  Disorders,^  Dr.  Dubois 
states  that  in  the  treatment  of  such  ailments,  it  is  essential 
not  to  confine  one's  therapeutic  effort  to  the  patients  alone, 
but  to  extend  it  to  those  who  live  with  them.  The  family 
must  be  considered  as  the  ultimate  unit  of  our  social  organ- 
ization,- and  any  plans  for  the  social  treatment  of  one  mem- 
ber of  the  group  must  take  into  consideration  the  effect  of 
such  treatment  upon  the  other  members  of  the  family,  for 
the  good  results  of  individual  treatment  often  crumble  away 
before  the  onslaughts   of   difficult  and  complex  group  or 

^Dubois,  Paul,  Psychic  Treatment  of  Nen'ous  Disorders,  1909.  p.  44. 
2  Devine,  Principles  of  Relief,  1904,  p.  77. 


303]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       161 

family  problems.  Just  as  in  medicine,  so  in  the  field  of 
social  science,  our  patients  and  their  families  must  be 
thought  of  as  integral  parts  of  a  given  whole. 

(a)  Death  of  Aged  Married  Men.  Turning  to  the 
deaths  of  husbands  and  fathers,  and  the  effect  of  their 
demise  upon  the  family  life  and  structure,  it  is  quite  ap- 
parent that  family  conditions  are  but  slightly  affected  when 
a  man  of  advanced  years  dies,  leaving  a  widow  and  several 
adult  children.  In  the  instances  in  which  this  happened, 
the  children  assumed  the  burden  of  supporting  the  entire 
household,  their  only  task  being  the  support  oi  an  aged 
mother  with  few  and  simple  wants.  The  presumption  is 
that  the  family  structure  will  continue  as  before  the  death 
of  the  patient,  until,  through  the  natural  withdrawal  of  the 
children  to  establish  new  families  of  their  own,  it  is  found 
advisable  to  take  the  widowed  mother  intO'  the  household  of 
one  of  the  children.  The  death  of  a  man  of  advanced  years, 
leaving  a  widow  of  about  the  same  age  but  no  children,  in- 
volves problems  of  a  more  complex  nature  than  the  mere 
adjustment  of  family  affairs  following  in  the  wake  of  the 
previous  instance.  There  are  three  alternatives  to  choose 
from ;  either  relatives  must  support  or  take  into  their  homes 
such  widows,  or  they  can  be  aided  financially  by  a  relief 
organization  and  allowed  to  board  with  friends,  or  provi- 
sion must  be  found  for  them  in  some  home  for  the  aged. 
None  of  the  wives  of  the  patients  considered  under  thisi 
heading  found  their  way  into  institutions,  as  they  were 
either  taken  in  by  relatives  or  subsidized  by  a  relief  organ- 
ization. 

(b)  Care  of  Dependent  Widows  and  Orphans.  Most 
of  the  serious  social  problems  following  upon  the  deaths  of 
married  men  would  naturally  fall  in  the  families  in  which 
there  were  one  or  more  minor  children  left  to  the  care  of  a 
penniless  mother.     Analysis  has  shown  that  in  these  cases 


l62     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [304 

relatives  in  comfortable  circumstances  sometimes  came  to 
the  rescue  of  the  family  in  distress,  making  all  the  necessary- 
provision  for  their  sustenance  and  comfort.  It  is  the  pro- 
verbial way  of  caring  for  such  dependents,  and  self-sacrific- 
ing relatives  of  this  calibre  are  fully  deserving  of  the  thanksl 
of  the  community,  even  though  such  service  should  be 
looked  upon  as  a  duty  and  an  obligation  rather  than  as  a 
favor.  The  difficulty  is,  however,  that  few  of  the  patients 
admitted  to  the  psychopathic  wards  of  Bellevue  Hospital 
and  subsequently  to  the  state  hospitals  have  immediate  rela- 
tives in  a  position  to  assume  such  serious  financial  obliga- 
tions. The  result  has  been  that  in  instances  where  the  de- 
ceased was  not  a  citizen  and  the  widow  was  left  with  no 
estate  and  several  minor  children,  she  has  had  to  wend  her 
way  to  a  relief  organization  for  the  support  of  her  children 
and  herself,  until  such  time  as  they  became  of  wage-earning 
age. 

The  effect  of  sexual  disease  in  the  husband  upon  the 
sterility  of  his  wife  is  a  well-recognized  phenomenon,  and 
it  is  not  surprising  therefore  that  there  were  a  number  of 
childless  widows  of  men  dying  in  the  state  hospitals, 
largely  with  a  diagnosis  of  general  paralysis.  Wives  learn- 
ing the  true  mental  and  physical  conditions  of  their  hus- 
bands have  in  many  instances  left  them  in  order  to  earn 
their  own  livelihoods ;  or,  where  the  affection  of  the  wife  for 
the  husband  was  not  sufficiently  destroyed  to  lead  her  to 
desert  the  sick  and  suffering  man,  she  has  gone  out  to  work 
as  soon  as  his  inability  further  to  support  her  and  himself 
became  apparent. 

Fortunately  for  some  of  the  widows  and  their  half- 
orphaned  children,  the  husbands  and  fathers  had  operated 
and  owned  some  small  retail  business  and  it  was  out  of  the 
income  from  this  source  that  several  of  the  families  managed 
to  support  themselves,  sometimes  with  the  occasional  finan- 


305]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       163 

cial  assistance  of  kind  friends  and  relatives.  Mental  disease 
often  i-ncapacitates  persons  for  a  long  period  of  time,  with 
the  result  that  they  hecome  unable  properly  to  discharge 
their  family  responsibilities.  In  a  number  of  cases  where 
there  was  a  combination  of  a  wife  and  minor  children  and 
a  husband  and  father  too  ill  mentally  to  work  regularly,  the 
wife  has  gone  into  industry  to  earn  sufficient  to  keep  the 
family  together.  She  has  either  left  the  children  at  home 
under  the  care  of  a  father  who  suffered  from  periodic  at- 
tacks of  mental  instability  and  alienation,  or  has  placed 
them  in  day  nurseries  or  with  friends  and  relatives  until 
her  return  from  the  shop  and  factory.  The  inadvisability 
of  permitting  such  a  father  to  be  the  guardian  of  the  young; 
children  throughout  the  day  is  quite  obvious,  but  no  agency 
is  as  yet  prepared  to  take  care  of  the  large  number  of  cases 
in  which  this  and  similar  incidents  are  of  almost  daily  oc- 
currence. This  is  but  another  indication  of  the  need  of 
concerted  action  throughout  the  community  if  the  problem 
of  the  insane  and  their  families  is  to  be  solved  along  em- 
pirical and  rational  lines.  At  present  such  family  problems 
are  met  in  the  best  way  known  to  the  immediate  relatives  and 
friends,  sometimes  with  the  aid  of  a  social  agency  unac- 
quainted with  the  special  and  peculiar  problems  involved  in 
the  adjustment  for  any  long  or  short  period  of  time,  of  the 
dependents  of  a  mentally  unbalanced  husband  and  father. 
Families  in  which  the  father  has  died  in  a  state  hospital 
leaving  a  wife  and  minor  children,  and  also  means  sufficient 
to  maintain  the  family  in  comfort,  present  few  problems 
needing  solution.  It  has  been  found  however,  that  often  the 
relatives  are  in  need  of  advice  regarding  the  probable  effect, 
if  any,  of  insanity  in  the  father  upon  the  children.  In  in- 
stances in  which  the  father  died  of  general  paralysis  the 
utility  of  Wasserman  tests  performed  upon  all  immediate 
members  of  the  family  is  readily  apparent,  and  invariably 


164     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [306 

information  of  this  nature  given  to  relatives  has  been  wel- 
comed and  quite  frequently  followed  out. 

Similar  to  the  foregoing  instance  are  the  cases  in  which 
the  father  was  a  citizen  and  where  consequently  the  mother 
was  granted  a  pension  on  behalf  of  her  minor  and  depend- 
ent children.  There  is  a  difference,  however,  in  that  in  the 
latter  cases  the  families  may  be  in  need  of  financial  assist- 
ance to  tide  them  over  until  their  case  is  finally  passed  upon 
by  the  Board  of  Child  Welfare  and  is  placed  on  the  pension 
role.  Some  instances  occurred  in  which  the  wife  herself 
was  a  patient  in  a  state  hospital  for  the  insane,  though  no 
minor  children  were  left  to  need  the  attention  of  a  social 
agency.  Had  there  been  such  children  the  obvious  plan  would 
have  been,  as  in  similar  situations  in  which  both  parents  are 
either  dead  or  mentally  incompetent,  to  place  them  with 
relatives,  or  for  a  child-caring  agency  to^  provide  for  them 
in  an  orphan  asylum  or  to  board  them  out. 

The  waves  of  immigration  in  the  years  preceding  the  war 
brought  large  numbers  of  single  as  well  as  married  men  to 
this  country.  Many  of  the  latter,  however,  arrived  here 
alone  in  order  to  establish  a  home  for  their  families  whom 
they  had  left  in  some  European  land,  their  plan  being  to 
send  for  their  wives  and  children  as  soon  as  they  had  saved 
sufficient  to  pay  for  the  passage  of  their  families  and  for 
the  new  household  they  intended  to  establish.  Unfortun- 
ately for  some,  the  plans  so  well  thought  out  went  wrong, 
due  altogether  to  the  fact  that  the  father  became  mentally 
unbalanced  before  he  could  send  for  the  family.  Such  cases 
are  indeed  sad,  though  there  is  nothing  that  can  be  done 
either  for  the  family  or  for  the  patient,  as  the  latter  has  to  be 
considered  as  a  single  man  without  any  family  responsibili- 
ties, at  least  during  the  period  of  his  illness.  The  question  of 
deportation  is  of  course  involved  in  some  instances,  though 
it  was  found  that  most  of  these  patients  had  been  in  this 


307]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       165 

country  beyond  the  five-year  limit  and  had  not  become 
pubhc  charges  prior  to  that  time. 

(c)  Family  Problems  following  Death  of  Mothers.  In 
the  cases  in  which  the  mother  of  the  family  died,  it  is  quite 
conceivable  that  a  widower,  upon  his  wife's  death,  should 
find  himself  seriously  embarrassed  in  making  provision  for 
the  care  of  his  children,  even  though  his  income  had  been 
sufiicient  to  care  for  the  entire  family.  As  is  well  recog- 
nized, in  the  normal  family  the  contribution  made  by  the 
mother  to  the  common  welfare  is  often  fully  equal  to  that 
of  the  father  even  though  it  is  not  so  readily  measured  in 
dollars  and  cents.  The  loss  of  the  mother  does  not  neces- 
sarily cause  the  family  of  the  wage-earner  to  become  de- 
pendent upon  outside  financial  aid,  though  the  assistance  of 
social  agencies  interested  in  the  care  and  welfare  of  child- 
ren is  often  necessary.  Due  often  to  particular  family  con- 
ditions, the  father  is  not  able  properly  to  care  and  provide 
for  his  orphaned  children,  and  he  is  thus  compelled  to  turn 
to  others  for  help.  The  natural  thing  is  that  he  should  first 
of  all  appeal  either  to  his  own  or  to  his  deceased  wife's  re- 
latives, so  that  his  children  may  be  quickly  provided  with 
a  proper  home  and  suitable  accommodations  essential 
for  their  future  well-being.  In  several  of  the  familiesi 
studied  it  was  the  relatives  who  came  to  the  help  of  the 
children,  either  because  of  the  strength  of  family  ties  or 
as  a  result  of  the  father's  inability  for  one  reason  or 
another  properly  to  provide  for  his  children. 

Sometimes  the  opposite  kind  of  situation  developed;  in- 
stead of  care  being  needed  for  the  children,  the  aged  father 
had  to  be  provided  for  by  his  adult  children.  This  never 
involved  any  serious  social  problem,  for  the  children 
usually  took  the  father  into  their  own  home  or  made  other 
provisions  for  his  maintenance  and  welfare. 

Emphasis  has  been  placed  upon  the  advisability  of  main- 


1 66     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [308 

taining  the  family  as  a  unit  whenever  possible.  The  plac- 
ing-out  of  children  either  in  institutions  or  in  boarding 
homes  is  only  a  make-shift  to  meet  a  condition  of  affairs 
for  which  there  seemingly  is  no  better  way.  In  many  in- 
stances far  better  results  are  obtained  if  one  of  the  children, 
especially  if  a  daughter,  is  old  enough  to  take  up  the  house- 
hold cares,  or  if  some  near  relative  of  the  family  is  in  a 
position  to  step  into  the  vacant  place.  During  the  first  few 
months  following  the  deaths  of  a  number  of  the  mothers, 
the  husbands  had  to  resort  to  the  expedient  of  boarding  out 
the  minor  children  because  of  inability  tO'  make  any  adjust- 
ments which  would  have  resulted  in  the  maintenance  of  the 
family  under  one  roof.  Other  fathers  found  it  necessary 
to  have  their  minor  children  committed  to  orphan  asylums, 
as  they  did  not  earn  sufficient  to  support  their  several  child- 
ren either  in  their  own  homes  or  in  foster  or  boarding  homes. 
The  financial  arrangement  always  insisted  upon  by  the 
Department  of  Public  Welfare  of  the  City  of  New  York  is 
that  the  father  must  regularly  pay  a  certain  amount  per 
week  to  the  Department  for  the  maintenance  and  support 
of  his  children,  the  amount  depending  upon  the  number  of 
children  committed  and  the  average  earnings  of  the  father. 
A  number  of  the  husbands  eventually  re-married  and  took 
their  children  of  the  first  marriage  with  them  into  the  new 
household,  thus  making  as  suitable  provision  for  their  care 
as  the  circumstances  would  allow. 

Childless  marriages  have  always  been  regarded  by  one 
school  of  thought  as  unnatural  and  uncalled-for,  particularly 
w^hen  both  the  husband  and  wife  are  in  good  mental  and 
physical  condition  and  are  in  a  position  properly  or  at 
least  adequately  to  provide  for  such  offspring  as  they  may 
have.  In  those  cases  in  which  the  wife  died  without  leav- 
ing any  children,  the  husband  had  no  family  problems  need- 
ing solution,  and  he  returned  to  the  status  of  a  single  man. 


309]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS      i6y 

From  the  point  of  view  of  society  as  a  whole,  it  was  pro- 
bably fortunate  tliat  a  few  of  the  married  women  who  died 
in  hospitals  for  the  insane  left  no  progeny,  for,  even  from 
the  little  we  know  at  present  regarding  the  inheritance  of 
mental  disease,  it  is  quite  probable  that  at  least  some  of  the 
children,  had  they  been  born,  would  have  become  afflicted 
with  some  form  of  mental  or  nervous  ailment. 

The  exact  classification  of  social  phenomena  is  frequently 
fraught  with  much  difficulty,  particularly  when  the  groups 
for  various  reasons  are  limited  in  number.  In  several  cases 
in  which  the  wife  and  mother  died  in  the  state  hospital,  the 
husband  had  not  been  able  to  and  did  not  provide  and  care 
for  his  children  even  prior  to  the  time  of  the  death  of  his 
wife.  There  were  a  number  of  causes  for  this,  among  them 
being  the  illness  of  the  father,  lack  of  sufficient  earnings, 
desertion,  etc.  The  action  taken  by  the  relatives  of  the 
couples  in  several  such  families  was  to  have  the  children 
placed  with  grandparents  or  other  immediate  relatives  dur- 
ing the  illness  of  the  mother,  and  remain  in  such  homes  after 
the  mother's  death.  There  were  one  or  two  cases  in  which 
the  mother  died  in  a  state  hospital  during  the  time  that  the 
husband  and  father  was  serving  in  the  army.  The  Home 
Service  Section  of  the  American  Red  Cross  readily  came  to 
the  assistance  of  the  dependent  children  by  placing  them  in 
boarding  homes  until  the  fathers  returned  home. 

(d)  Widowed.  The  total  number  of  widowed  persons 
dying  in  state  hospitals  was  rather  small,  numbering  7  males 
and  10  females.  The  social  problems  presented  by  this 
group  were  almost  insignificant,  due  altogether  to  the  fact 
that  of  the  males,  the  ages  at  death  were  between  55  and  80 
years,  while  of  the  10  females,  9  ranged  in  age  between  68 
and  89  years ;  the  tenth  patient  was  a  widow  of  33  years, 
whose  two  minor  children  had  been  placed  with  relatives 
some  time  prior  to  her  death  as  she  had  been  ill  for  a  long 


l68     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [310 

time  previous  to  her  admission  to  the  state  hospital.  None 
of  the  aged  widowers  or  widows  left  any  dependents,  as 
such  children  as  they  had  were  all  self-supporting  adults. 

(e)  Divorced.  There  were  only  two  cases  of  divorced 
persons  dying  in  the  state  hospitals,  and  both  of  these  were 
men  who  had  been  sick  for  many  years  prior  to  their  ad^ 
mission  to  the  institution  in  which  they  passed  away. 
Under  the  divorce  laws  of  the  State  of  New  York  a  divorce 
can  be  granted  only  for  infidelity.  On  grounds  of  in- 
sanity the  marriage,  under  certain  conditions,  may  be  an- 
nulled. From  the  facts  in  hand  regarding  these  two  cases 
it  appears  that  in  one  a  divorce  was  obtained  by  the  wife  in 
another  country ;  in  the  other,  though  the  patient  claimed  at 
the  time  of  his  admission  to  the  psychopathic  ward  of 
Bellevue  Hospital  that  he  had  been  divorced  by  his  wife, 
it  was  later  determined  that  she  had  only  obtained  a  separa- 
tion from  him. 

(f)  Modification  of  Marriage  and  Divorce  Laws.  The 
injustice  of  the  stringent  divorce  laws  oi  New  York  State 
to  the  innocent  party  to  a  marriage  in  which  one  of  the 
participants  at  an  early  date  or  even  eventually  becomes; 
hopelessly  insane,  is  apparent  to  all  students  of  social  pro- 
blems. The  time  is  overdue  when  New  York  should  follow 
in  the  footsteps  of  other  states  and  liberalize  the  obsolete 
and  unfair  laws  relating  to  divorce.  In  no  group  of  social 
facts  that  can  be  presented  is  this  more  strongly  evidenced 
than  in  a  consideration  of  the  misery  and  unhappiness  and 
blasted  lives  of  young  manhood  and  young  womanhood  fol- 
lowing insanity  in  a  young  married  person.  Marriage 
licenses  in  New  York  contain  the  following  statement  which 
both  parties  are  required  to  sign :  "  I  have  not  to  my  know- 
ledge been  infected  with  any  venereal  disease  or  if  I  have 
been  so  infected  within  five  years,  I  have  had  a  laboratory 
test  within  that  period  which  shows  that  I  am  now  free 


31 1  ]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       169 

from  infection  from  any  such  disease."  A  further  state- 
ment might  well  be  added  to  marriage  licenses — one  which 
would  inform  the  healthy  partner  to  a  marriage  contract  of 
former  attacks  of  insanity  in  the  other. 

VII.    PAROLE  SYSTEM  OF  STATE  HOSPITALS 

Before  discussing  the  discharged  cases  and  the  facts 
brought  out  as  a  result  of  following  them  up  some  time  sub- 
sequent to  their  discharge  from  the  state  hospitals,  it  might 
be  well  to  present  the  outstanding  features  of  the  parole  and 
out-patient  departments  of  the  state  hospitals.  It  is  to 
these  departments  that  discharged  patients  are  referred  and 
to  which  they  are  expected  to  report  during  the  parole 
period,  usually  of  six  months,  though  occasionally  of  longer 
duration. 

(a)  Development  of  Out-Patient  Departments.  In  191 3 
the  legislature,  at  the  suggestion  of  the  State  Charities  Aid 
Association,  passed  a  law  authorizing  each  of  the  state 
hospitals  to  establish  an  out-patient  department,  assign  a 
physician  to  it  and  employ  a  field  agent  or  social  worker. 
At  that  time  this  law  was  referred  tO'  by  competent  authority 
as  the  most  important  law  in  behalf  of  the  insane  passed  in 
a  generation.^  It  was  some  years,  however,  before  all  the 
thirteen  state  hospitals  had  organized  this  branch  or  de- 
partment of  their  work  and  engaged  the  services  of  a  social 
worker.  Had  sufficient  funds  been  available  and  the  new 
activity  been  initiated  with  more  vigor,  it  is  apparent  that 
a  considerable  number  of  persons  who  eventually  were  com- 
mitted to  the  state  hospitals  because  of  the  lack  of  com- 
petent advice  or  early  treatment  would  have  been  saved  the 
rather  unpleasant  experience  of  residence  as  patients  in  a 
state  hospital  for  the  insane. 

1  S.  H.  C,  28th  A.  R.,  p.  352. 


lyo     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [312 

The  out-patient  departments  and  the  parole  activities  of 
the  state  hospitals  are  naturally  inter-related,  for  it  is  to  the 
clinics  established  under  the  law  of  191 3  that  the  parole 
patients  report ;  and  similarly,  the  social  worker  assigned  to 
the  out-patient  department  also  looks  after  the  parole  cases. 
The  effects  oi  the  mental  clinics  upon  the  hospitals  are 
several;  they  provide  a  means  whereby  the  hospital  can 
supply  medical  supervision  to  its  patients  even  when  they 
live  at  a  distance  from  the  institution  itself;  they  provide 
an  inconspicuous  place  to  which  sensitive  patients  are  willing 
to  come  when  they  would  hesitate  to  return  to  the  hospital ; 
and  also,  by  giving  parole  patients  an  opportunity  re- 
gularly and  frequently  to  see  a  physician  who  understands 
them,  the  hospital  is  enabled  to  keep  a  number  of  patients 
on  parole  who  would  otherwise  have  to  return.  The  clinics 
are  also  of  value  to  the  hospital  physician,  as  he  is  given  the 
opportunity  to  do  preventive  work  and  meet  types  of  cases 
in  the  milder  forms  which  rarely  reach  the  state  hospital.^ 
There  would  be  little  hesitancy  in  denominating  such  a 
system  of  out-patient  and  parole  departments  of  state  hos- 
pitals a  great  force  and  factor  in  preventive  work  and  of 
the  highest  form  of  medical  and  social  usefulness,  pro- 
vided only  that  its  standard  of  service  and  effectiveness  was 
high.  Whether  or  not  such  is  the  case  at  present  may  be 
readily  judged  from  the  facts  presented  in  the  following' 
paragraphs. 

(b)  Extent  and  Effectiveness  of  Parole  System.  The 
procedure  followed  by  the  writer  in  attempting  to  arrive  at 
a  fair  and  at  the  same  time  convincing  conclusion  as  to  the 
value  and  usefulness  of  the  out-patient  and  parole  activi- 
ties, was  to  consult  the  parole  records  of  the  patients  dis- 
charged from  both  the  Manhattan  and  Central  Islip  State 

1  The  Parole  System   of  New   York   State  Hospitals,  published  by- 
New  York  State  Charities  Aid  Assn.,  Nov.,  1917. 


313]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       171 

Hospitals,  limiting  the  study  however,  to  those  cases  which 
have  been  considered  in  the  preceding  chapters.  There 
was  some  difficulty  in  attempting  to  carry  out  this  plan,  due 
altogether  to  the  fact  that  the  field  agent  or  social  worker 
attached  to  one  of  the  hospitals  frankly  admitted  that  her 
routine  work  was  so  heavy  and  the  number  of  parole 
patients  so  large,  that  she  had  been  unable  toi  keep  any  re- 
cords of  value  during  the  time  to  which  this  study  is 
limited.  A  year  later,  with  some  clerical  assistance,  she  was 
in  a  better  position  to  keep  some  kind  of  record  for  each 
patient  out  on  parole,  usually  not  more  than  a  note  by  the 
•examining  physician  that  the  patient  reported  at  the  clinic 
and  was  discharged  from  parole  on  a  given  date.  The 
records  of  the  clinics  of  the  other  hospital  were  somewhat 
more  complete,  due  to  the  fact  that  the  social  worker  had 
a  sufficient  knowledge  of  stenography  and  typewriting  to 
enable  her  to  take  the  dictation  of  the  clinic  physician  and 
.transcribe  the  notes  into  the  records  of  the  patients  re- 
porting at  the  clinics.  Following  are  excerpts  taken  from 
the  parole  records  of  several  patients: 

In  the  case  of  patient  No.  13,671  the  report  read,  "He 
(the  patient)  does  not  agree  that  the  abnormal  sexual  sen- 
sations are  any  less  since  he  left  the  hospital ;  conversation 
tends  to  be  quite  disconnected  and  poorly  constructed.  HisI 
parole  is  due  to  expire  in  a  few  days  and  he  is  discharged 
from  the  clinic." 

In  No.  14,011,  a  case  of  dementia  praecox,  katatonic 
type,  the  clinical  report  stated  that  the  patient  was  childish 
-and  not  fully  recovered ;  also  that  "  his  condition  is  of  course 
far  from  satisfactory,  but  his  parole  having  expired  three 
days  ago,  nothing  can  be  done  except  to  discharge  him  from 
the  clinic."  This  patient  was  engaged  to  be  married  at 
•the  time  of  his  last  visit  to  the  clinic,  and  the  notes  quoted 
were  written  at  that  time. 


172     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [314 

No.  14,140  reported  to  the  clinic,  and  it  was  found  that 
"  he  was  not  ahcgether  recovered,  but  discharged  from  the 
clinic  since  parole  period  expired  within  a  few  days  of 
visit  to  clinic."  A  few  months  later,  the  patient  was  read- 
mitted to  the  hospital. 

The  report  in  No.  13.936  reads,  "Discharged  at  the  end 
of  parole  period  though  should  ordinarily  be  continued 
under  care." 

In  the  case  of  No.  13,738  the  record  shows  that  after  his 
discharge  from  the  state  hospital,  the  patient  came  to  the 
clinic  once  and  was  not  followed  up.  Also,  the  record  of 
the  first  and  only  visit  reads  that  "  OAving  to  his  poor 
English  he  (the  patient)  did  not  appear  to  understand  the 
advice  of  the  examiner."  Some  months  later  this  patient 
was  readmitted  to  the  hospital. 

It  is  needless  to  point  out  the  implications  of  the  problem 
as  brought  out  by  citing  the  above  cases,  which  were  taken 
at  random  and  are  typical  of  much  of  the  work  in  the 
clinics  at  the  present  time.  It  should  not  be  gathered  that 
nothing  at  all  is  done,  for  out  of  a  considerable  number  of 
patients  paroled  from  one  of  the  hospitals,  the  writer  found 
that  practically  every  patient  who  had  been  paroled  re- 
ported to  the  clinic  and  was  seen  by  the  physician  at  least 
once  during  the  six  months  parole  period.  This  in  itself 
was  of  value,  though  the  general  criticism  of  the  work  as  a 
whole  is  that  not  sufficient  is  now  being  done  by  the  state  for 
paroled  patients  and  such  as  come  tO'  the  clinics  for  advice. 
The  social  workers  are  able  in  a  number  of  cases  to  assist 
the  patients  in  placing  themselves  in  positions  and  in  other- 
wise serving  them.  As  has  already  been  pointed  out,  how- 
ever, it  is  impossible  for  one  worker  to  follow  up  paroled 
and  discharged  patients  from  any  one  of  the  large  state 
hospitals,  and  so  to  serve  them  and  their  families  that  the 
maximum  amount  of  service  will  be  rendered  to  these  un- 


315]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       173 

fortunates.  This  would  involve  a  large  expenditure  of 
money  in  a  kind  of  service  which  the  state  is  not  prepared  to 
render.  The  only  funds  that  the  state  hospitals  are  em- 
powered to  give  directly  to  the  patients  or  their  relatives  are 
provided  for  in  the  following  section  of  the  Insanity  Law  :  ^ 

No  patient  shall  be  discharged  or  paroled  from  a  state  hospital 
without  suitable  clothing  adapted  to  the  season  in  which  he  is 
discharged  or  paroled ;  and  if  it  can  not  be  otherwise  obtained, 
the  steward  shall,  upon  the  order  of  the  superintendent,  furnish 
the  same,  and  money  not  exceeding  twenty-five  dollars,  to  defray 
his  necessary  expenses  until  he  can  reach  his  relatives  or  friends, 
or  find  employment  to  earn  a  subsistence. 

In  only  a  few  of  the  cases  discharged  or  paroled  is  any 
money  granted  to  tide  the  patients  over  until  they  find  em- 
ployment. Beyond  that  and  the  clinic  work  the  state  is  not 
at  present  supplying  any  further  mental  hygiene  service  to 
discharged  or  paroled  patients  or  others  in  need  of  such  ser- 
vice, the  term  "  mental  hygiene  service  "  being  used  in  its 
broadest  sense. 

VIII.    PAROLED  AND  DISCHARGED    PATIENTS 

Mention  has  already  been  made  of  the  four-fold  division 
into  which  the  patients  have  been  classified  for  the  purpose 
of  surveying  the  results  of  state  hospital  care  and  treatment. 
Regarding  the  first  group,  made  up  of  those  still  in  the  state 
hospitals  and  without  dependents  or  family  responsibilities, 
it  is  seemingly  obvious  that  very  little,  if  anything,  could 
be  accomplished  by  a  detailed  study  of  the  families  of  these 
persons,  more  especially  from  the  point  of  view  of  their 
social  needs  and  requirements.  It  would  be  possible  to  un- 
earth facts  relative  to  the  heredity,  behavior  prior  to  com- 

1  Chap.  27  of  the  Consolidated  Lazvs,  Sect.  95. 


174     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [316 

mitment,  industrial  history,  etc.,oi  the  patients.  To  ob- 
tain information  of  scientific  value,  it  would  be  necessary  to 
presuppose  siifficient  knowledge  and  power  of  observation- 
and  interpretation  of  given  facts  on  the  part  of  relatives  and. 
friends,  matters  in  which  large  numbers  have  been  found 
woefully  lacking.  This  is  so  marked  that  little  value  can 
be  attached  to  statements  obtained  along  these  lines  from 
relatives  of  many  of  the  patients. 

In  the  second  group  are  classified  patients  who  prior  to 
admission  to  a  state  hospital  had  certain  family  responsibili- 
ties, and  at  the  end  of  one  year  were  still  confined  in  the  in- 
stitutions. The  commitment  of  such  persons  involved 
family  readjustments  of  one  kind  or  another,  which  have 
already  been  dwelt  upon. 

(a)  Details  of  Survey  Form.  The  last  group  contains 
all  those  patients  discharged  or  paroled  from  the  state  hos- 
pitals within  a  year  after  admission,  and  who  were  per- 
mitted to  leave  the  hospitals  on  parole  for  six  months.  In 
order  to  study  this  group  carefully  it  was  found  to  be  both, 
advisable  and  necessary  to  devise  and  draw  up  a  form  that 
would  serve  as  the  basis  for  the  social  investigation,  and  as 
a  questionnaire  and  guide  to  the  investigator.  Aside  from 
this,  it  was  proposed  to  obtain  as  much  reliable  information 
as  possible  regarding  the  impoTtant  aspects  of  the  life  of 
the  patient  after  leaving  the  institution.  The  form,  was^ 
therefore  divided  into  four  main  headings,  namely,  (a) 
mental,  (b)  medical  or  physical,  (c)  social,  and  (d)  recrea- 
tional. The  thought  was  that  this  kind  of  division  would 
cover  all  the  important  factors  regarding  the  lives  of  the 
patients  and  would  at  the  same  time  bring  out  the  facts  re- 
lative to  our  present  inadequacies  in  providing  and  caring 
for  the  mentall}''  sick. 

Under  Mental,  the  aim  was  to  ascertain  the  condition  of 
the  patient  at  least  a  year  after  discharge,  the  result  of 


317]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       175 

the  hospital  treatment,  after-care  or  mental  hygiene  clinic 
attended,  and  needs  unfulfilled  or  not  being  met  by  the 
community. 

The  effect  of  the  medical  or  physical  condition  of  a 
person  upon  his  mental  well-'being  is  so  thoroughly  recog- 
nized that  it  needs  but  little  further  elucidation.  This  is 
particularly  true  of  persons  who  have  been  so  ill  mentally 
that  their  commitment  to  a  state  hospital  or  other  institu- 
tion has  been  found  necessary.  A  discharged  or  paroled 
mental  case  with  any  one  of  a  large  number  of  serious  or 
troublesome  physical  ailments  will  have  his  ultimate  recovery 
or  improvement  seriously  retarded  or  even  prevented  unless 
such  physical  difficulty  receives  timely  and  expert  attention. 
It  might  properly  be  expected  that  most  if  not  all  remediable 
physical  ailments  be  attended  to  while  the  patient  is  still  in 
the  state  hospital,  or,  at  least  just  prior  tO'  his  parole;  and 
if  not  then,  through  the  help  of  the  after-care  workers,  by 
whom  patients  can  be  taken  to  general  hospitals.  Be- 
cause of  the  overcrowded  conditions  in  the  state  hospitals 
any  attempt  adequately  to  care  for  the  physical  ailments 
of  the  patients  would  result  in  a  state  of  congestion  that 
would  be  intolerable.  The  result  is  that  but  little  can  be 
attempted  in  the  way  of  giving  patients  the  attention  they 
actually  require  if  their  recovery  is  to  be  expedited  and  the 
possibility  of  a  relapse  eliminated  as  far  as  possible. 

In  a  survey  of  this  kind  more  definite  and  accurate  in- 
formation can  be  obtained  regarding  the  social  conditions 
than  of  either  the  mental  or  physical  status.  Under  the 
classification  Social,  the  aim  is  to  determine  the  condition 
and  progress  of  the  discharged  patient,  his  relationship  to 
his  family,  the  needs  of  the  family  group,  and  what  the  com- 
munity has  done  or  is  doing  to  help  the  family  meet  these 
needs.  Some  might  question  the  necessity  and  advisability 
of  conducting  such  an  inquiry,  presumably  assuming  that 


1^6     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [318 

the  two  problems,  state  hospital  care  and  family  readjust- 
ment are  separate  and  distinct  problems  and  not  to  be  con- 
sidered in  conjunction  with  each  other.  To  such,  it  is 
apropos  to  indicate  that  worry  over  lack  of  employment  or 
even  failure  to  be  placed  in  a  suitable  position,  family  and 
financial  difficulties,  and  innumerable  other  conditions  that 
arise  in  family  or  group  life  influence  mental  health,  more 
especially  in  the  cases  of  those  prone  to  mental  disease. 
The  mere  fact  that  a  patient  has  been  discharged  from  a 
state  hospital  in  an  improved  or  much  improved,  or  even 
recovered  condition,  all  o^f  these  being  relative  terms  only, 
does  not  assure  him  that  when  he  returns  to  his  family  and 
reenters  industry  he  will  progress  as  any  normal  individual 
might  reasonably  expect  to  after  a  short  or  prolonged  vaca- 
tion, or  even  after  residence  in  a  general  ho'spital.  The 
safer  assumption  is  that  he  will  need  guidance  and  advice, 
and  probably  financial  or  other  assistance  for  some  time 
after  leaving  the  institution. 

A  matter  too  frequently  ignored  in  considering  the  needs 
of  mental  cases  is  the  important  part  that  suitable  forms  of 
recreation  can  be  made  to  play  in  facilitating  the  improve- 
ment and  recovery  of  those  who  are  or  have  been  mentally 
ill.  It  is  because  of  this  that  one  of  the  main  divisions  of 
the  questionnaire  deals  with  the  recreation  of  the  discharged 
and  paroled  patients.  Included  under  this  heading  are 
kinds  of  recreation  sought ;  result  of  participation  in  recrea- 
tional activities,  such  as  the  improvement  in  sociability,  etc.; 
and  also,  recreational  needs  unfulfilled,  either  because  the 
patient  does  not  himself  understand  the  value  of  proper  re- 
creation in  the  upbuilding  and  maintenance  of  health,  or 
because  of  the  lack  of  recreational  facilities  in  the  neighbor- 
hood in  which  the  patient  lives. 


319]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       177 
IX.    SURVEY  OF  PAROLED  AND  DISCHARGED  PATIENTS 

The  investigation  of  a  comparatively  large  number  of 
patients  paroled  and  discharged  from  state  hospitals  involves 
difficulties  not  usually  met  with  in  surveys  concerned  with 
other  groups  of  persons.  There  are  several  reasons  for 
this.  Patients  are  at  times  brought  to  psychopathic  wards 
of  general  hospitals  from  places  other  than  their  homes,  and, 
due  to  their  mental  condition,  their  names  and  more  often 
their  correct  addresses  cannot  be  obtained.  During  their 
stay  in  a  state  hospital  from  which  they  are  subsequently 
paroled  or  discharged,  it  frequently  happens  that  no  correct 
address  is  ascertained,  even  though  the  social  workers  of 
the  state  hospitals  aim  to  get  in  touch  with  the  friends  or 
relatives  of  all  patients  prior  to  their  departure  from  the 
institutions.  Many  patients  have  no  family  or  other  ties 
in  the  city  and  they  are  consequently  lost  track  of  once 
they  are  discharged  from  the  hospitals,  unless  they  return 
to  the  clinics  or  to  the  hospitals  following  another  attack. 

It  was  found  furthermore,  that  a  number  of  families 
moved  away  shortly  after  a  member  of  the  family  was  com- 
mitted to  a  state  hospital  for  the  insane,  and  all  attempts  to 
locate  them  were,  as  a  rule,  unsuccessful.  Partly  respon- 
sible for  this  was  the  circumstance  that  in  making  this  sur- 
vey the  paroled  and  discharged  cases  were  not  followed  up 
for  a  year  or  more  after  they  left  the  different  hospitals. 
As  previously  outlined,  this  lapse  of  time  was  permitted  in 
order  that  after-care  workers  of  the  state  hospitals  might  do 
what  they  could  for  the  patients,  and  that  they  themselves 
might  have  time  for  readjustment  before  a  valuation  of  the 
effectiveness  of  these  methods  was  undertaken.  During 
this  time  many  patients,  probably  not  wishing  to  return  to 
the  neighborhood  in  which  they  had  been  known  as  queer  or 
*'  crazy,"  removed  without  leaving  a  forwarding  address  or 
telling  their  neighbors  their  new  place  of  residence.     Other 


178     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [320 

patients  left  the  city  or  state  and  facts  relative  to  their  con- 
dition could  not  be  obtained,  All  in  all,  approximately 
thirty  per  cent  of  the  paroled  and  discharged  patients  were 
lost  track  of  for  the  reasons  given  above,  and  the  observa- 
tions that  follow  are  based  upon  the  remaining  seventy 
per  cent,  a  sufficiently  large  number  to  provide  an  adequate 
and  satisfactory  picture. 

X.    MENTAL  CONDITION 

Table  24  shows  that  of  the  784  patients  committed  to  the 
Manhattan  and  Central  Islip  State  Hospitals,  285  were  dis- 
charged within  a  year  after  admission  as  recovered,  improved 
or  unimproved.  As  already  indicated,  approximately  30  per 
cent  or  85  of  the  discharged  patients  could  not  be  located 
when  the  attempt  was  made  to  follow  them  up.  Of  the 
remaining  200  patients,  20  per  cent  were  found  to  have  fully 
recovered,  practically  all  of  them  having  originally  been 
diagnosed  as  cases  of  manic  depressive  insanity ;  28  per  cent 
showed  much  improvement,  these  also  largely  representing 
cases  of  manic  depressive  insanity;  19  per  cent,  composed 
maiinly  of  cases  of  dementia  praecox,  showed  some  slight 
improvement;  8  per  cent  showed  no  improvement  whatso- 
ever; 20  per  cent  returned  to  the  state  hospitals  within  the 
year ;  and  5  per  cent  died  within  a  year  after  discharge. 

From  these  facts  it  would  seem  that  about  50  per  cent  of 
the  paroled  and  discharged  patients  were  able  to  return  to 
their  former  environment  and  occupations,  with  the  chances 
in  their  favor  of  a  future  normal  life.  A  question  might 
well  be  asked  at  this  point  as  to  how  many  patients  of  the 
other  50  per  cent  might  have  improved  sufficiently  to  have 
made  it  unnecessary  for  them  either  to  return  to  the  state 
hospitals  for  further  care,  or  to  remain  at  home  in  partial 
or  total  idleness,  had  there  been  an  adequate  follow-up 
system  to  help  them  and  other  patients  with  advice  and 


32 1  ]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS      179 

personal  service.  It  is  of  course  impossible  tO'  answer  the: 
question  definitely  at  this  time,  though  we  know  enough  of 
the  value  and  possibilities  of  social  service  in  the  field  of 
mental  hygiene  to  feel  convinced  that  the  state  would  have 
saved  much  eventually  had  mental  hygiene  work  been  estab- 
lished on  a  broad  and  comprehensive  scale. 

Many  of  the  paroled  patients  who  report  to  the  state  hos- 
pital clinics  seemingly  do  so  out  of  fear  that  they  will  be 
returned  to  the  hospitals  unless  they  come  tO'  advise  with 
the  doctors  regarding  their  condition  during  the  six  months 
for  which  they  are  paroled.  In  the  end  it  is  probably  a 
good  thing  that  they  feel  a  compulsion  to  seek  advice,  parti- 
cularly since  most  of  the  paroled  patients  are  kindly  dis- 
posed towards  the  doctors  and  nurses,  realizing  as  they  do 
that  a  genuine  service  has  been  rendered  them  and  their 
families  during  a  period  of  severe  illness.  Should  the 
Jewish  patients  find  themselves  in  need  of  further  medical 
advice  and  treatment  after  their  parole  period  has  expired, 
they  do  not  often  go  to  the  state  hospital  clinics,  where  their 
language  is  not  sufficiently  understood  and  their  peculiar 
psychology  is  not  grasped.  They  go  rather  to  their  family 
or  lodge  doctors  who  are  not  competent  to  advise  them ;  or, 
in  some  instances,  to  well-known  and  thoroughly  reliable 
psychiatrists;  or  to  the  mental  hygiene  clinics  maintained 
by  the  Free  Synagogue,  where  psychiatrists  oi  established 
reputations  and  nurses  and  social  workers  trained  in  mental 
hygiene  work  are  prepared  to  assist  them  socially,  financially 
and  otherwise. 

In  the  questionnaire  used,  when  asking  the  questions  "  Are 
needs  for  mental  treatment  being  met,"  and  "  Any  further 
provision  for  mental  treatment  needed,"  the  idea  was  to 
learn  wherein  present  facilities  were  inadequate  and  in 
need  of  being  strengthened  and  augmented.  The  state- 
ments already  made  regarding  the  shortcomings   of   our 


l8o     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [322 

present  provisions  for  the  treatment  of  paroled  and  dis- 
charged patients  were  fully  verified  as  a  result  of  the  study 
of  these  patients  and  their  needs.  Plans  for  the  develop- 
ment of  a  constructive  program  to  meet  the  situation  will  be 
presented  in  a  following  chapter. 

XI.    PHYSICAL  CONDITION 

There  are  few  bodily  diseases  but  what  are  accompanied 
by  changes  more  or  less  severe  in  the  mental  condition  of 
the  persons  affected.  Consequently,  a  person  affected  men- 
tally and  at  the  same  time  suffering  from  some  physical 
ailment,  will  stand  a  better  chance  of  regaining  his  mental 
health,  at  least  in  certain  types  of  cases,  if  the  physical 
ailment  is  properly  attended  to  without  undue  delay.  These 
are  fairly  well-established  facts  and  account  for  the  ques- 
tions asked  of  paroled  and  discharged  patients  regarding 
their  physical  coqdition. 

It  is  almost  needless  to  remark  that  in  making  the  survey 
it  was  not  feasible  to  give  each  paroled  and  discharged 
patient  a  physical  examination.  Dependence  had  to  be 
placed  in  almost  every  case  on  what  was  learned  regarding 
the  physical  condition  of  the  patient  while  detained  in  the 
psychopathic  wards  of  Bellevue  Hospital,  and  on  such  other 
information  as  could  be  obtained  from  a  reading  of  the 
case  records  in  the  state  hospitals,  the  parole  records  in  the 
clinics,  and  from  the  relatives  and  patients  themselves  after 
their  discharge  from  the  institutions.  Despite  all  these 
sources  of  information,  it  was  not  possible  to  obtain  much 
reliable  data  regarding  the  physical  condition  of  the  major- 
ity of  the  patients  considered.  It  is  easy  to  understand  why 
this  should  be  so.  The  psychopathic  services  of  Bellevue 
and  other  hospitals  are  at  present  primarily  concerned  with 
deciding  whether  or  not  a  given  patient  is  insane  and  should 
be  committed  to  a  state  hospital.     The  law  allows  only  ten 


323]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       181 

days  in  which  to  determine  this  fact,  and  does  not  take  into 
consideration  the  advisability  of  thorough  physical  examin- 
ations and  treatment  in  a  general  hospital  or  one  similarly 
equipped,  of  mental  cases  suffering  from  physical  ailments. 

The  medical  staffs  of  the  state  hospitals  are  trained  in  the 
diagnosis  and  treatment,  such  as  it  can  be  under  present 
overcrowded  conditions,  of  mental  diseases ;  and,  while  they 
are  quite  competent  to  treat  minor  physical  ailments,  it  does 
not  need  much  explanation  to  make  it  obvious  that  they 
cannot  in  all  fairness  be  expected  to  be  specialists  in  alJ 
branches  of  medicine. 

Specialists  are  occasionally  consulted  for  a  few  O'f  the 
patients,  but  this  seems  to  be  the  exception  rather  than  the 
rule.  To  cite  just  an  instance :  a  former  university  teacher 
is  a  patient  in  one  of  the  state  hospitals  in  the  metropolitan 
district.  He  has  been  diagnosed  as  a  case  of  dementia  prae- 
cox  of  two  or  more  years  standing,  but  despite  that  his  mind 
is  still  quite  alert.  He  is  also  a  sufferer  from  a  severe  eye 
affection  which  seems  to  aggravate  his  mental  condition. 
For  many  weeks  he  had  asked  that  an  eye  specialist  be 
called  in  to  advise  him  as  to  whether  or  not  he  should  wear 
shaded  or  other  glasses,  for  which  he  was  able  and  willing  to 
pay.  The  physician  on  the  ward  explained  that  the  patient 
would  have  to  wait  until  a  member  of  the  board  of  managers 
of  the  hospital,  who  was  at  the  same  time  an  eye  specialist, 
could  find  the  time  to  visit  him. 

Experience  in  mental  hygiene  clinics  covering  a  period  of 
years  has  shown  conclusively  the  need  of  thorough  physical 
examinations  and  of  the  early  treatment  of  the  many  minor 
and  major  illnesses  from  which  a  considerable  number  of 
persons  suffer.  The  need  for  this  kind  of  service  is  greater 
in  mental  cases ;  and,  with  adequate  facilities,  no  person 
coming  under  the  care  of  the  state  hospitals  should  be 
paroled  before  his  physical  ailments  have  been  attended  to. 


l82     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [324 

At  least,  no  patient  should  be  discharged  from  parole  until 
the  clinic  physicians  and  nurses  have  seen  to  it  that  he  hasi 
been  put  in  touch  with  a  dispensary  or  hospital  where  his 
physical  needs  will  be  properly  looked  after. 

XII.    SOCIAL  CONDITION 

The  responsibility  of  the  community  to  care  and  provide 
for  its  sick  members  is  well  recognized  by  all,  and  acted  upon 
according  to  the  standards  prevailing  in  different  sections 
of  the  country.  One  of  the  aims  of  the  survey  was  to  learn 
what  the  community  does  through  its  various  social  agencies 
to  maintain  in  health  those  who  have  been  mentally  ill  and 
to  prevent  their  relapse.  In  order  to  get  at  the  facts  in  this 
matter,  the  following  questions  were  asked  of  paroled  and 
discharged  patients :  present  occupation  and  earnings ;  regu- 
larity of  employment  since  leaving  the  hospital;  reasons, 
if  any,  for  non-emplo^Tnent ;  assistance  being  rendered  to 
patient  by  any  agency,  with  name  of  agency  and  nature  of 
service ;  assistance  rendered  to  family  of  patient  while  latter 
was  in  the  hospital ;  and  social  needs  of  the  family  and  the 
patient  not  being  met. 

(a)  Employment  of  Paroled  Patients.  In  considering 
the  question  of  employment,  the  patients  must  quite  naturally 
be  divided  into  males  and  females,  particularly  as  far  as  the 
adults  are  concerned,  for  nearly  all  the  married  women  re- 
sumed their  former  household  tasks  of  caring  for  their 
homes  and  families.  Some  of  the  unmarried  young  women 
found  it  more  advisable  to  remain  at  home  and  help  in 
caring  for  it,  than  to  return  to  the  office  or  factory  in 
which  had  formerly  been  employed.  In  such  instances 
the  change  seemed  to  have  quite  a  salutary  effect  and  helped 
materially  in  the  improvement  of  the  patient,  both  physically 
and  mentally.  On  the  whole,  the  majority  of  the  patients 
returned  to  the  trades  and  occupations  in  which  they  had 


325]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       183 

been  engaged  prior  to  their  commitment,  for  their  absence 
from  industry  for  a  period  of  months  made  it  necessary  that 
they  begin  to  earn  money  at  the  eariiest  possible  time.  This 
does  not  mean  that  they  were  all  placed  shortly  after  being 
paroled  or  discharged,  for  it  must  be  remembered  that  many 
were  formerly  engaged  in  seasonal  occupations,  and  if  they 
left  the  hospital  during  the  slack  season  it  was  difficult  if 
not  impossible  for  them  to  obtain  work.  On  the  other 
hand,  if  they  happened  to  leave  the  institution  during  the 
busy  season  and  at  once  returned  to  the  shops  and  factories 
with  the  desire  to  make  up  the  lost  earnings,  their  health 
was  often  adversely  affected. 

Most  of  those  who  returned  to  their  former  occupations 
in  industry  were  cases  of  manic  depressive  insanity,  and 
they  frequently  found  it  impossible  to  continue  regularly  at 
their  trades  because  they  had  not  fully  recovered  and  could 
not  stand  the  strain.  Others  could  not  work  at  all  as  they 
had  been  ill  since  their  discharge  from  the  hospital,  re- 
maining at  home  and  subsisting  on  the  bounty  of  friends 
and  relatives.  This  was  true  of  practically  all  cases  of 
dementia  praecox,  most  of  them  working  occasionally  only 
and  for  short  periods  of  time.  There  were  some  among 
these  cases  who  became  so  discouraged  because  of  their 
inability  to  retain  a  position  that  they  finally  gave  up  trying 
to  find  work  and  remained  at  home  altogether,  in  some  in- 
stances developing  anti-social  habits  of  conduct.  A  few  of 
the  recovered  and  much  improved  cases  of  manic  depressive 
insanity  established  themselves  in  small  retail  businesses, 
and  seemingly  prospered  both  mentally  and  financially. 

Concerning  the  earnings  of  discharged  patients,  from 
what  has  already  been  said  regarding  the  non-regularity 
of  employment,  it  is  seen  that  there  must  have  been,  as 
there  was,  a  decrease  in  the  earning  power.  This  entailed  in 
a  number  of  instances  a  severe  financial  loss  to  the  families 


l84     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [326 

concerned,  though  it  might  have  been  avoided  had  there 
existed  a  social  agency,  either  as  an  adjunct  to  state  hos- 
pitals or  otherwise,  to  obtain  suitable  employment  for  such 
as  could  not  readily  find  it  of  their  own  accord. 

(b)  Financial  Relief  to  Families  of  Patients.  The 
number  of  cases  that  had  to  be  referred  to  a  relief  agency 
were  not  very  large.  Several  families  in  which  the  father 
and  wage-earner  had  been  ill  for  a  considerable  time  were 
already  known  to  the  United  Hebrew  Charities,  the  Jewish 
relief  organization,  and  it  was  merely  a  question  of  referring 
the  family  for  further  financial  assistance  until  the  patient 
was  discharged  from  the  hospital  and  was  able  to  reenter 
industry.  Other  families,  unknown  to  any  relief  society,  had 
to  be  taken  under  care  while  the  wage-earner  was  confined 
in  a  hospital.  Usually  the  relief  given  was  either  a  sub- 
sidy to  make  up  for  an  insufficient  family  income,  or,  where 
there  were  no  wage-earners  or  relatives  to  call  upon,  the 
relief  agency  had  to  assume  the  full  financial  responsibility 
as  best  it  could.  Due  to  the  understandable  hesitancy  on  the 
part  of  recipients  of  financial  relief  to  disclose  the  extent 
of  the  aid  given  them  by  the  United  Hebrew  Charities,  it 
was  often  impossible  to  obtain  accurate  facts  concerning  the 
amount  of  relief  granted  in  particular  cases.  In  the  year 
19 1 9  the  United  Hebrew  Charities  spent  on  families  of  the 
insane  4  per  cent  or  $12,400  of  its  total  expenditure  for 
relief.  Of  recent  years  there  has  been  some  agitation  car- 
ried on  to  make  the  provisions  of  the  law  granting  a  pen- 
sion to  fatherless  children  who  remain  at  home  under  the 
care  of  their  mothers,  applicable  also  to  children  whose 
fathers  have  been  committed  to  a  state  hospital  for  the 
insane.  Under  the  provisions  of  Chapter  700,  Laws  of 
1920,  the  Legislature  of  New  Yo'rk  provided  that  "  a  board 
of  child  welfare  may  in  its  discretion,  grant  an  allowance  to 
any  dependent  mother  whose  hubsand  is  an  inmate  in  a  state 


327]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       185 

institution  for  the  insane."  This  law  became  effective 
July  I,  1920. 

(c)  Dependent  Children  Committed  to  Orphan  Asylums. 
Aside  from  the  problem  of  financial  relief  of  families  in 
distress,  there  was  the  question  of  the  disposition  of  minor 
children.  The  difficulty  was  most  acute  when  the  mother  of 
young  children  was  committed  to  a  state  hospital.  The 
social  service  department  in  Bellevue  Hospital  helped  to 
provide  for  and  refer  to  proper  agencies  most  of  the  children 
in  need  of  being  placed.  Some  of  the  ways  used  to  dispose 
of  such  children  properly  are  herewith  enumerated,  different 
methods  having  been  found  necessary  in  different  circum- 
stances. Children  were  boarded  together  with  the  father 
during  the  illness  of  the  mother  and  until  her  discharge  from 
the  hospital;  children  were  committed  to  the  Hebrew 
Orphan  Asylum,  the  Hebrew  Sheltering  Guardian  Society 
and  the  Hebrew  Infant  Asylum,  through  the  Department  of 
Public  Charities  (now  the  Department  of  Public  Welfare)  ; 
the  father  paid  neighbors  to  care  for  the  children;  board- 
ing homes  were  found  for  the  children,  the  father  paying 
for  their  care;  and  children  were  taken  in  by  relatives.  The 
records  of  the  Hebrew  Orphan  i\sylum  indicate  that  out 
of  approximately  1,200  children,  12  per  cent  have  been 
committed  there  because  of  insanity  on  the  part  of  either 
parent;  at  the  Hebrew  Sheltering  Guardian  Society,  with  a 
population  of  about  525  children  the  percentage  is  5.1; 
while  of  350  infants  at  the  Hebrew  Infant  Asylum  11.5 
per  cent  are  there  because  of  insanity  in  one  or  both  parents. 

In  presenting  the  above  facts  regarding  the  social  con- 
dition of  paroled  and  discharged  patients,  the  attempt  has 
been  merely  to  indicate  what  some  of  the  problems  are  that 
beset  families  in  which  insanity  overthrows  the  social  of 
economic  stability  oif  the  group.  It  was  not  intended  that 
a  detailed  social  study  should  be  made  of  all  the  families 


1 86     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [328 

concerned,  for  such  a  task  would  not  only  require  a  great 
deal  of  space,  but  would  also  prove  quite  valueless,  as 
practically  all  the  salient  points  involved  have  already  been 
broiught  out  and  mentioned.  In  the  following  chapter,  in 
which  individuals  and  families  are  studied  in  greater  detail, 
the  methods  employed  to  meet  the  mental,  physical,  social 
and  recreational  problems  that  arise  in  families  in  which 
there  is  an  insane  person,  are  discussed  at  greater  length. 

XIII.    RECREATIONAL  OPPORTUNITIES 

Very  few,  if  any,  of  the  patients  and  their  relatives  who 
were  interviewed  in  making  this  study,  realized  the  import- 
ant part  that  proper  forms  of  recreation  could  be  made  to 
play  in  the  improvement  and  recovery  of  patients  considered 
sufficiently  well  to  be  returned  to  their  former  environ- 
ment. The  attempt  was  made  to  obtain  the  facts  pertaining 
to  this  particular  phase  of  the  problem  as  a  whole  by  ask- 
ing the  following  questions :  What  is  being  done  to  provide 
recreation  for  the  patient;  how  does  the  patient  spend  his 
spare  time;  is  there  any  improvement  in  the  sociability  of 
the  patient  since  discharge  from  the  hospital ;  what  agency, 
if  any,  is  helping  the  patient  to  readjust  himself  along  re- 
creational lines,  and  how ;  what  needs  for  recreation  are 
not  being  met.  As  a  matter  of  fact,  it  was  hardly  worth 
while  to  ask  any  but  the  last  question,  for  in  nearly  every 
instance  there  was  a  total  lack  of  understanding  and  appre- 
ciation of  the  therapeutic  value  of  proper  forms  of  recrea- 
tion. It  was  furthermore  found  that  the  needs  of  the 
patients  were  not  being  met,  and  that  no  agency  was  in- 
terested in  helping  such  patients  to  grapple  with  their 
specific  problems.  Of  the  four  divisions,  namely,  the  men- 
tal, physical,  social  and  recreational,  the  latter  was  dis- 
covered to  be  the  most  neglected  field  of  service,  one  in 
which  no  effort  was  expended  to  help  the  patient. 


329]      SURVEY  OF  786  ADMISSIONS  TO  HOSPITALS       187 

The  shortcomings  of  our  present  method  of  caring  for  the 
insane  both  within  and  without  institutional  walls  have  been 
more  fully  illustrated  by  the  facts  presented  in  this  chapter. 
From  what  has  preceded  as  well  as  from  these  facts,  it  has 
become  apparent  that  certain  adjuncts  to  the  present  state 
hospital  system  will  have  to  be  developed,  ere  it  can  be  ex- 
pected that  persons  adjudged  insane  and  committed  to-  state 
hoispitals  for  the  insane  will  receive  the  service  and  atten- 
tion that  they  and  their  families  require  in  order  to  return 
those  mentally  ill  to  normal  society  and  to  normal  ways  of 
living  at  the  earliest  possible  time. 


CHAPTER  V 
Social  Treatment  of  the  Insane 

i.  introduction 

Grotius  is  reputed  to  have  stated  that  "  the  care  of  the 
human  mind  is  the  noblest  branch  of  medicine."  Since  his 
day  we  have  come  to  reahze  that  the  care  of  the  human 
mind,  or  rather  of  the  insane  and  bordedine  cases  of  in- 
sanity, is  not  ahogether  a  problem  for  the  physician  alone, 
but  that  other  agents  and  forces  in  the  community  must 
either  be  called  upon  or  brought  into  being  in  order  to 
assist  the  medical  men  to  meet  this  problem.  This  becomesi 
apparent  when  considering  the  routine  through  which  the 
average  person  who  becomes  mentally  ill  passes  during  the 
period  of  his  illness. 

Whenever  a  person  becomes  irrational,  markedly  de- 
pressed or  excited,  or  shows  anti-social  tendencies  which 
have  their  roots  in  the  mental  state  of  the  individual,  the  im- 
mediate friends  and  relatives  are  quite  likely  to  assume  that 
some  form  of  hospital  care  and  treatment  is  needed. 
Usually  the  advice  of  the  family  physician  is  sought,  and 
acting  upon  his  suggestion  or  that  of  the  police  who  are  cal- 
led in,  the  patient  is  transferred  to  the  psychopathic  ward 
of  the  general  hospital  in  the  community.  Once  there  the 
patient  is  subjected  to  a  mental  examination  and  observa- 
tion of  his  actions.  If,  at  the  end  of  a  few  days,  a  positive 
diagnosis  is  made  and  the  patient  is  found  to  be  insane  in 
the  legal  sense  O'f  the  word,  he  is  committed  to  a  state  hos- 
pital were  he  remains  until  it  is  found  advisable  to  parole 
188  [330 


331]  SOCIAL  TREATMENT  OF  INSANE  189 

or  discharge  him;  or  if  suffering  from  a  chronic  disease, 
until  he  dies,  unless  previously  removed  by  relatives  or 
others.  Prior  to  leaving  the  state  hospital  the  patient  is 
given  a  parole  card  and  instructed  to  report  to  the  clinic 
or  out-patient  department  of  the  hospital  for  further  oberva- 
tion  and  advice.  The  work  of  these  clinics  has  already  been 
summarized  and  nothing  further  need  be  added  at  this 
point.  However,  referring  the  patient  to  the  clinic  and  ad- 
vising him  when  he  reports  is  to  all  intents  and  purposes  the 
last  step  the  state  takes.  The  fact  stands  out  that  some- 
thing further  should  and  must  be  done  if  the  insane  and 
borderline  cases  of  insanity  in  the  community  are  to  be  pro- 
perly and  adequately  served. 

(a)  Dei'clopment  of  Mental  Hygiene  Movement.  The 
initiation  o^f  the  mental  hygiene  movement,  at  least  insofar 
as  it  concerned  the  organization  of  state  and  national 
societies  for  the  dissemination  of  facts  gathered  through 
surveys  and  original  studies,  was  largely  due  tO'  the  publica- 
tion of  the  autobiography,  "  A  Mind  That  Found  Itself,"  / 
of  Clifford  W.  Beers,  who,  since  its  organization  in  1909, 
has  been  the  secretary  of  the  National  Committee  for 
Mental  Hygiene.  It  is  undoubtedly  true  that  the  publication 
of  this  very  interesting  and  well-nigh  epoch-making  volume 
came  at  a  time  when  certain  groups  in  the  community  were 
giving  much  thought  to  the  general  problem  of  the  insane, 
and  that  Mr.  Beers'  book  served  to  crystalHze  opinion  and 
helped  to  bring  together  those  who  shortly  thereafter  be- 
came the  founders  of  the  National  Committee  for  Mental 
Hygiene. 

The  organization  of  this  group  followed  closely  the  move- 
ment for  the  establishment  of  hospital  social  service  depart- 
ments in  all  general  hospitals.  Dr.  Richard  C.  Cabot  of 
Boston  organized  the  first  medical  social  service  depart- 
ment in  this  country,  when  in  1905  he  developed  a  social 


igo     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [332 

service  division  in  the  out-patient  department  of  the  Massa- 
chusetts General  Hospital.  The  reasons  for  the  organiza- 
tion of  this  new  branch  of  work  were  that  the  physician 
treating  a  patient  could  become  acquainted  with  only  certain 
phases  of  the  mental  and  physical  condition  of  the  patient, 
and  that  it  was  necessary  to  call  in  the  trained  social  service 
worker  to  assist  the  physician  in  making  a  more  accurate 
diagnosis  and  in  rendering  the  prescribed  treatment  more 
effective.  This  new  form  of  service  was  at  first  designed 
primarily  for  those  who  came  to  the  out-patient  depart- 
ment of  the  general  hospital.  Since  then  the  movement  has 
spread  to  practically  all  the  large  general  hospitals  in  the 
country,  and  the  social  service  departments  now  serve  both 
the  ward  and  dispensary  patients.  The  state  hospitals  for 
the  insane  in  New  York,  following  the  development  of  the 
,  hospital  social  service  idea,  appointed  social  service  workers 
to  follow-up  as  many  patients  as  they  could,  to  assist  at  the 
clinics,  and  to  obtain  such  additional  information  regarding 
particular  patients  as  was  found  necessary  by  the  attending 
physicians. 

To  those  who  became  interested  in  the  better  care  of  the 
insane,  it  early  became  evident  that  the  service  rendered  by 
the  state  to  patients  lacked  one  very  essential  element,  and 
that  was  proper  mental  hygiene  care.  Organized  work  in 
mental  hygiene  may  be  described  in  various  ways,  depending 
upon  one's  viewpoint  and  special  interest.^  The  viewpoint 
expressed  here  is  not  that  of  the  physician  but  rather  that 
of  the  layman,  interested  in  according  to  mental  cases  that 
kind  of  service  which  had  its  origin  in  medical  social  ser- 
vice, but  which  has  during  the  past  decade  developed  its 
own  methods  of  work  and  means  of  serving.     The  state 

1  Beers,  C.  W.,  "  Organized  Work  in  Mental  Hygiene,"  Mental 
Hygiene,"  Jan.,  1917,  p.  81. 


333]  SOCIAL  TREATMENT  OF  INSANE  igi 

hospitals,  due  to  financial  and  legal  difficulties,  have  stop- 
ped virtually  at  the  point  at  which  the  hospital  social  ser- 
vice movement  began,  and  it  has  been  left  to  private  organ- 
izations to  develop  the  technique  oif  rendering  mental 
hygiene  service. 

II.    ORGANIZATION   AND  DEVELOPMENT  OF  A  MENTAL 
HYGIENE  AGENCY 

Following  closely  the  organization  of  a  social  service 
department  by  Dr.  Cabot  in  Boston,  a  group  of  public 
spirited  men  and  women  helped  to  organize  such  a  depart- 
ment in  Bellevue  Hospital,  New  York  Oity,  by  providing 
the  funds  with  which  to  carry  on  certain  very  important 
phases  of  the  work  for  which  the  city  did  not  and  could 
not  appropriate  money.  Because  of  the  very  large  number 
of  patients  admitted  to  the  hospital,  as  well  as  treated  in 
the  out-patient  departments,  the  problem  of  supplying 
adequate  social  service  to  all  groups  of  patients  presented 
difficulties,  some  of  which  have  not  as  yet  been  surmounted. 
It  should  be  noted  that  to  Bellevue  Hospital  come  patientsi 
from  practically  all  parts  of  the  greater  city;  and  that,  be- 
sides its  general  wards  for  medical  and  surgical  cases,  it 
also  has  a  psychopathic  department  which  handles  approx- 
imately 6,000  patients  a  year.  Receiving  such  a  large 
number  of  patients,  it  is  apparent  that  many  races  and 
nationalities  are  represented  in  the  lists  of  admissions. 

Bellevue  Hospital  necessarily  admits  a  rather  large  num- 
ber of  Jewish  patients  annually,  for  though  the  Jews  of 
New  York  have  organized  and  maintain  several  general 
hospitals  to  which  Jews  largely  seek  admission,  neverthe- 
less the  number  of  beds  is  quite  insufficient  tO'  accommodate 
all  who  want  treatment  in  the  semi-private  Jewish  institu- 
tions. In  order  to  serve  beween  5,000  and  6,000  Jewish 
patients  who  are  admitted  to  Bellevue  Hospital  annually, 


192     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [334 

and  of  whom  about  1,100  come  to  the  psychopathic  wards, 
a  Jewish  agency,  namely  the  social  service  department  of  the 
Free  Synagog-ue,  has  undertaken  to  serve  particularly  the 
Jewish  patients,  most  of  whom  feel  out  of  place  in  an  in- 
stitution in  which  the  Mosaic  dietary  laws  are  not  observed 
and  in  which  their  language,  when  not  English,  is  not 
understood  and  their  own  distinctive  psychology  not  fully 
grasped. 

With  the  development  of  the  work,  the  realization  that 
the  psychopathic  cases  demanded  a  different  kind  of  service 
became  apparent.  It  was  found,  for  instance,  that  the 
resident  psychiatrists  often  believed  that  certain  cases  could 
recover  outside  of  a  state  hospital  more  readily  than  they 
could  within  the  walls  of  such  an  institution ;  and  yet,  they 
did  not  feel  safe  in  sending  such  patients  back  to  their  own 
homes,  in  which  the  mental  difficulty  had  developed  and  to 
relatives  who  did  not  understand  the  nature  of  the  ailment 
or  the  proper  care  of  the  patient.  Since  approximately  71 
per  cent  of  the  patients  admitted  to  the  psychopathic  wards 
were  committed  to  a  state  hospital,  the  social  service  de- 
partment was  often  called  upon  to  advise  the  family  and 
help,  financially  and  otherwise,  in  their  readjustment  to 
new  social  conditions  until  the  father  or  mother  or  other 
member  of  the  family  was  discharged  from  the  state  hos- 
pital. A  further  phenomenon  also  aroused  interest  in  the 
need  for  a  special  division  to  care  for  mental  cases,  and 
that  was  the  considerable  number  of  patients  readmitted 
from  year  to  year. 

It  was  these  facts,  as  well  as  the  realization,  through  daily 
contact  with  psychopathic  cases  and  their  problems,  of  the 
shortcomings  of  the  provisions  made  by  the  state  and  city 
officially,  and  by  the  commimity  as  a  whole,  that  prompted 
the  organization  of  a  mental  hygiene  division  as  a  part  of 


335]  SOCIAL  TREATMENT  OF  INSANE  193 

the  social  service  department  of  the  Free  Synagogue/  The 
series  of  steps  in  the  development  of  this  particular  mental 
hygiene  agency  is  probably  more  or  less  typical  of  the  way 
in  which  other  similar  agencies  have  and  will  come  into 
being,  unless  through  propaganda  and  widespread  educa- 
tion, various  communities  can  be  made  to  realize  the  duty 
they  owe  to  the  mentally  sick  in  their  midst. 

III.    ACTIVITIES  OF  A  MENTAL  HYGIENE  AGENCY 

Stating  the  matter  briefly,  the  chief  purposes  of  any 
society  or  committee  for  mental  hygiene  are :  conservation 
of  mental  health;  prevention  of  nervous  and  mental  dis- 
orders and  mental  deficiency ;  and  improvement  in  the  care 
and  treatment  of  those  suffering  from  any  O'f  these  disorders. 
Though  methods  of  work  and  the  amount  of  attention  given 
to  some  activities  vary,  practically  all  societies  for  mental 
hygiene  are  seeking  to  achieve  their  aims  in  the  following 
ways:  (a)  by  means  of  campaigns  of  education;  (b) 
through  social  service  activities;  (c)  by  surveys  and  special 
studies;  (d)  by  influencing  the  enactment  of  proper  and 
necessary  legislation;  (e)  by  cooperating  with  other  agen- 
cies to  achieve  better  results  in  the  care  and  treatment  of 
mental  cases. 

Several  of  the  above  items  in  a  mental  hygiene  program 
explain  themselves  and  need  no  further  elaboration.  The 
matter  of  social  service  activities,  however,  presents  a  de- 
finite problem  which  has  many  ramifications.  To  begin 
with,  there  is  the  question  of  the  organization  and  the  per- 
sonnel of  the  clinic  to  which  the  patients  taken  under  care 
are  referred.  The  usual  organization  requires  that  there 
be  a  physician  trained  in  psychiatry,  a  mental  hygiene  or 
psychiatric   social    worker,    and    a   stenographic   secretary. 

^  State  Hosp.  Comm.,  23th  Annual  Report,  p.  451. 


194     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [335 

Having  carefully  selected  the  staff  for  each  clinic,  it  be- 
comes necessary  to  determine  upon  the  scope  of  work  which 
the  agency  operating  the  clinics  deems  it  can  successfully 
carr}^  through.  The  two  clinics  maintained  by  the  social 
service  department  of  the  Free  Synagogue  at  a  cost  of  about 
$6,000  per  year  for  each  clinic,  aim  to  render  the  following 
services  to  all  those  who  are  referred  to  them  by  various 
individuals  and  social  agencies  in  the  community: 

1.  To  treat  psychoneuroses  and  all  so-called  borderline 
cases  of  mental  diseases  in  adults  and  children. 

2.  To  inform  the  wage  earners  and  others  truthfully 
about  conditions  for  the  care  of  the  insane  in  the  state 
hospitals,  to  explain  the  significance  of  commitment  to 
them  and  to  assist  them  in  committing  proper  cases 
to  the  state  hospitals  as  well  as  to  private  sanatoria, 
suitable  to  the  needs  of  the  patients  and  the  means  of 
the  family. 

3.  To  make  careful  individual  study  of  each  case  by  keep- 
ing in  close  touch  with  the  individual  and  his  surround- 
ings. 

4.  To  arrange  for  the  social  care  of  both  patient  and 
family  whenever  social  needs  appear. 

5.  To  facilitate  the  convalescent  care  of  patients  in  need 
of  this  service,  especially  of  those  discharged  from 
institutions. 

6.  To  assist  convalescents  and  others  in  obtaining  suitable 
employment  and  to  aid  in  readjusting  them  to  their 
environment. 

To  carry  out  the  program  as  outlined  above,  it  becomes 
necessary  to  call  for  the  cooperation  of  various  agencies  in 
the  community,  such  as  orphan  asylums,  child-placing  in- 
stitutions, relief  organizations,  convalescent  homes,  general 
and  special  hospitals  for  the  treatment  of  physical  ailments,. 


337]  SOCIAL  TREATMENT  OF  INSANE  195 

employment  agencies,  and  a  number  of  others,  all  of  which 
have  been  found  to  be  essentials  in  properly  caring  for  men- 
tal hygiene  cases.  The  Free  Synagogue  clinics  and  those 
associated  in  their  work,  do  what  they  themselves  can  in 
providing  for  the  mental,  physical,  social  and  recreational 
needs  of  the  patient  and  the  family  of  which  he  or  she  is 
a  part.  The  cooperation  and  help  of  other  agencies  is 
sought  whenever  it  is  felt  that  the  patient  or  the  family  is 
in  need  of  such  additional  service  as  the  mental  hygiene 
agency  is  not  as  yet  prepared  to  render,  or  as  is  altogether 
and  properly  the  function  oi  another  type  of  agency. 

IV.    TYPICAL  CASES  OF  A  MENTAL  HYGIENE  AGENCY 

The  kind  of  cases  that  are  referred  to  a  mental  hygiene 
agency  are  naturally  of  many  sorts  and  include  practically 
all  varieties  and  classifications.  In  the  activities  of  such  an 
agency,  decision  must  be  made  at  an  early  period  as  to  the 
kinds  of  patients  that  can  be  more  or  less  successfully  treated 
and  served,  and  as  to  which  categories  must  be  referred  to 
other  agencies  and  institutions.  Thus,  it  has  been  found 
in  the  climes  mentioned  that  all  mental  defectives  must  be 
referred  to  other  organizations,  as  the  attempt  is  to  deal 
only  with  such  cases  as  present  definite  psychoses  or  neuro^ 
ses,  or  a  borderline  condition  O'f  either  of  these  groups  of 
ailments.  In  the  pages  that  follow,  typical  cases  that  have 
been  referred  to  and  served  by  a  mental  hygiene  agency 
over  a  period  of  years  will  be  presented  in  outline  form. 
Because  of  the  fact  that  certain  types  of  patients  predomin- 
ate not  only  in  the  psychopathic  wards  and  in  the  state 
hospitals,  but  also  in  the  mental  hygiene  clinics  as  well, 
several  cases  will  be  presented  under  certain  headings  and 
only  one  or  two  tmder  such  classifications  as  appear  less 
frequently  in  the  admissions  to  hospitals  and  clinics. 

A  word  should  be  said  regarding  the  outline  according  to 


igS     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [338 

which  the  study  of  the  cases  was  made.  Following  the 
usual  order  adhered  to  in  state  hospitals  for  the  insane,  the 
diagnosis  is  presented  first;  then  follows  as  much  of  the 
family  history  regarding  insanity  in  the  family  as  has  been 
ascertained ;  the  personal  history  of  the  patient ;  and  a  state- 
ment regarding  the  onset  of  the  psychosis.  This  ends  the 
first  divison  of  the  outline.  In  the  second  part  or  division, 
is  presented  the  method  pursued  by  the  mental  hygiene 
agency  in  attempting  to  serve  tlie  patient  and  his  family, 
and  the  work  done  to  meet  or  help  solve  the  mental,  physical, 
social  and  recreational  problems  of  the  patient  and  his  de- 
pendents. Finally,  the  result  of  the  care  bestowed  upon 
the  patient  and  his  family  by  the  mental  hygiene  agency  and 
the  other  organizations  and  institutions  whose  services  had 
to  be  called  upon,  is  stated  in  a  thoroughly  unbiased  way. 

V.    CASE  STUDIES 


Diagnosis. 

Family 
History. 

Personal 
History. 

Onset  of 
Psychosis. 


manic  depressive  insanity 
Case  1 

Manic  depressive  insanity,  depressed  type,  with 
psychoneurotic  symptoms. 

Sister  of  patient  in  a  state  hospital  for  five  years 
with  a  diagnosis  of  dementia  praecox. 

Male;  age  35;  born  in  Russia;  came  to  United 
States  2 1  years  ago ;  clothing  operator ;  has  wife  and 
seven  minor  children. 

A  few  weeks  before  coming  to  the  clinic,  patient 
was  riding  in  the  subway  and  suddenly  his  head 
began  to  pain,  he  felt  dizzy  and  could  not  go  home 
alone.  His  whole  body  shook ;  could  not  sleep  at 
night ;  felt  sick  and  like  crying  all  the  time.  His 
condition  was  worse  in  the  morning  than  later  in  the 
day.  Hands  felt  weak  and  became  easily  tired ;  was 
depressed  ;  felt  as  if  he  had  a  wound  on  top  of  his 
head.  Had  feeling  of  inadequacy.  Had  been  ner- 
vous and  tormented  by  peculiar  sexual  ideas  for  sev- 
eral years. 


339] 


SOCIAL  TREATMENT  OF  INSANE 


197 


Method 

Mental.  '  Patient  came  to  clinic  a  number  of  times  within  a 
few  months,  but  showed  no  improvement.  Insisted  he 
wanted  to  enter  a  state  hospital  as  a  voluntary  patient 
as  he  could  not  remain  at  home  with  his  wife  and 
children,  for  they  aggravated  his  condition.  Did  not 
merely  want  to  stay  away  from  home  but  also  to  be 
where  his  wife  could  not  come  to  see  him  regularly 
and  annoy  him.  Arranged  for  patient  to  enter  a  state 
hospital  on  a  voluntary  commitment.  Remained  there 
,  .  about  nine  months,  leaving  the  institution  in  an  im- 
proved condition.  He  returned  home  to  his  family 
and  worked  for  a  year  as  a  newsstand  attendant. 
Suddenly  left  his  work  and  returned  as  a  voluntary 
patient  to  the  state  hospital,  where  he  has  remained  for 
about  a  year.  He  does  not  wish  to  go  home  as  he 
fears  to  assume  the  responsibility  of  caring  for  his  large 
family  and  to  live  with  his  wife.  Mother  of  latter 
died  in  an  insane  asylum  and  daughter  is  nervous, 
high-strung,  hyper-sexual,  and  makes  unusual  sexual 
demands  upon  her  husband  when  he  is  at  home. 
Patient  prefers  to  remain  in  the  state  hospital  until  he 
has  fully  recovered ;  has  shown  marked  improvement 
and  expects  to  leave  the  institution  within  a  few 
months. 

Physical.  Little  was  necessary  to  be  done  for  the  patient,  ex- 

cept to  give  him  a  thorough  physical  examination  and 
assure  him  there  was  nothing  wrong  with  him  physi- 
cally. Looked  after  the  physical  conditions  of  wife 
and  children ;  provided  set  of  teeth  for  wife. 

Social.  Wife  of  patient  insisted  that  she  could  not  care  for 

seven  small  children  when  her  husband  was  away  from 
home,  as  they  made  her  very  nervous.  To  prevent  a 
breakdown,  two  children  were  committed  to  an  orphan 
asylum.  This  relieved  mother  greatly.  Family  pro- 
vided with  rent,  living  expenses,  clothing,  etc.  during 
time  that  patient  was  and  has  been  in  state  hospital. 
Children  sent  to  vacation  homes  during  summer. 

Recreational.  When  out  of  hospital  patient  was  advised  and  en- 
couraged to  take  long  walks,  to  pass  spare  time  in: 
parks,  etc.    Recreation  provided  for  wife  and  children.. 


198 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[340 


Diagnosis. 
F.  H. 
P.  H. 


Psychosis. 


Mental. 


Result 

Patient  still  in  state  hospital,  and  is  expecting  to 
return  home  within  a  few  months  in  a  much  improved 
condition.  Social  service  work  has  aimed  properly  to 
care  for  family  while  the  patient  was  in  hospital,  to 
adjust  the  family  preparatory  to  his  homecoming,  and 
to  educate  the  wife  as  to  what  should  be  her  proper 
attitude  towards  patient  when  he  returns  from  the 
hospital.  Frequent  visits  made  to  patient  in  hospital 
by  worker  to  help  him  develop  a  greater  sense  of  re- 
sponsibility towards  his  family  and  a  better  under- 
standing of  his  wife. 

Case  2 

Manic  depressive  insanity. 

Negative. 

Male;  age  38;  born  in  Austria;  U.  S.  18  years; 
clothing  operator ;  married ;  wife  and  five  minor  chil- 
dren. 

For  three  years  patient  suffered  cramps  in  abdomen 
and  pains  in  upper  and  lower  limbs.  Following  death 
of  sister-in-law  became  very  nervous  and  upset;  could 
not  sleep ;  imagined  he  saw  the  dead  woman.  Became 
depressed  and  quiet.  Year  and  a  half  before  coming 
to  clinic  had  an  attack  of  manic  depressive  insanity, 
lasting  for  a  few  days.  While  at  work  became  excited 
and  mixed  up ;  did  not  sleep  for  a  few  nights.  Later 
complained  of  pains  on  top  of  head,  sleeplessness  and 
inability  to  tolerate  any  noises.  Had  suicidal  thoughts ; 
occasionally  things  became  dark  before  his  eyes ;  noises 
in  ears ;  while  at  work  and  away  from  home  imagined 
some  calamity  had  befallen  family. 
Method 

Patient  reported  at  clinic  every  two  weeks  for  sev- 
eral months;  later,  as  mental  condition  improved, 
these  visits  were  made  every  month  or  two;  patient 
visited  regularly  at  home  by  mental  hygiene  worker. 
Wife  of  patient  developed  a  sympathetic  condition  and 
also  had  to  be  treated  at  clinic.  Family  under  care  for 
three  and  a  half  years. 


.341] 


SOCIAL  TREATMENT  OF  INSANE 


199 


Physical.  Examined  physically  at  clinic  and  advised  regarding 

personal  habits,  diet,  etc.  Because  of  complaints  re- 
garding cramps  and  pains  in  upper  and  lower  limbs, 
had  X-ray  taken  of  stomach ;  patient  found  to  be  suf- 
fering from  a  gastric  ulcer,  which  seemed  to  be  the 
cause  of  most  of  his  difficulties.  Successful  operation 
performed  for  an  ulcer  of  lesser  curvature  of  stomach. 
Sent  patient  to  convalescent  home  following  discharge 
from  hospital.  Physical  needs  of  wife  and  children 
attended  to. 

Social.  During  entire  time  that  patient  and  his  family  were 

under  care,  supplied  family  with  rent  and  living  ex- 
penses whenever  patient  was  unable  to  work,  clothed 
the  entire  family,  and  provided  such  other  things  as 
were  needed,  as  an  abdominal  belt  following  operation. 
Family  visited  regularly  by  nurse  and  mental  hygiene 
worker;  provided  employment  for  patient  in  a  model 
factory,  where  he  could  work  according  to  his  strength. 

Recreational.  Patient  advised  by  clinic  physician  as  to  kind  of 
recreation  best  suited  to  his  needs ;  provided  with 
tickets  to  high-class  concerts. 

Result 

Patient  has  fully  recovered,  both  physically  and 
mentally.  His  wife  recovered  as  soon  as  symptoms 
presented  by  patient  disappeared.  Patient  now  earning 
high  wages,  has  moved  family  to  better  and  large 
quarters,  and  status  of  entire  family  has  been  raised. 

Case  3 

Diagnosis.         Manic  depressive  insanity. 

F.  H.  Father  insane. 

P-  H,  Female;  age  27;  born  in  Russia;  U.  S.  1^  years; 

housework ;  married  five  years ;  two  children. 

Psychosis.  After  birth  of  second  child  became  melancholy,  de- 

jected, could  not  sleep ;  spoke  sparingly ;  cried  during 
night;  feared  fate  of  father;  continually  complained 
of  head  being  mixed-up ;  attempted  suicide  by  inhal- 
ing gas ;  showed  no  impairment  of  memory,  but  lacked 
insight  into  her  condition. 


200     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [342 


Physical. 


Social. 


Mefhad 

Mental.  Sent  patient  to  a  private  sanatorium  for  four  months ; 

came  home  in  an  improved  condition ;  following  this, 
she  came  to  clinic  regularly  for  two  years  where  she 
was  examined  and  advised  by  physician.  Home  of 
patient  visited  by  mental  hygiene  worker,  several 
times  a  week  immediately  after  discharge  from  sana- 
torium and  at  regular  intervals  thereafter. 

Ailments  attended  to  at  dispensaries,  accompanied 
by  nurse  or  mental  hygiene  worker. 

Children  boarded  out  while  patient  was  in  sanator- 
ium; worker  helped  patient  adjust  herself  to  condi- 
tions at  home;  advised  and  trained  in  proper  care  of 
children;  advised  as  to  care  of  self,  personal  habits, 
household  management,  etc.  Case  continued  for  four 
years. 

Recreational.      Advised  as  to  proper  recreation ;  walks,  outings,  etc. 
Taken  out  for  walks  by  worker. 

Result 

Became  completely  readjusted  and  made  full  re- 
covery. Had  no  relapse  several  years  after  care  had 
been  discontinued. 

Case  4 

Manic  depressive  insanity,  depressed  t3^e. 

Unascertained. 

Female;  age  27;  born  in  Russia;  U.  S.  3  years; 
housework  ;  married  ;  two  children. 

Suffered  a  depression  caused  by  fatigue ;  showed  de- 
bility; feeling  of  insufficiency;  insomnia;  anorexia; 
unable  to  do  any  work  or  care  for  self  or  household. 
Complained  of  pains  and  aches  all  over  body;  became 
easily  excited. 

Method 

Mental.  Sent   to  a  private  sanatorium  but   refused   to  stay 

there  more  than  two  weeks,  complaining  that  the  asso- 
ciations there  made  her  feel  worse.  Brought  to  clinic 
regularly,  where  she  was  examined,  and  both  she  and 


Diagnosis. 
F.  H. 
P.  H. 

Psychosis. 


343] 


SOCIAL  TREATMENT  OF  INSANE 


201 


her  husband  advised  regarding  care  of  patient.  Men- 
tal hygiene  worker  visited  patient  frequently  at  her 
home. 

Physical,  Complaints  and   ailments  attended   to   at  hospitals 

and  dispensaries,  accompanied  by  worker.  Needs  of 
children  looked  after. 

Social.  Unemployment  of  husband  necessitated  supplement- 

ing family  income  and  providing  clothing.  Patient 
advised  and  shown  how  properly  to  care  for  self,  for 
children  and  for  home. 

Recreational.       Advised. 

Result 

Two  years  after  original  attack  patient  feeling  very 
much  improved.  No  further  need  to  attend  clinic  and 
has  not  had  another  attack. 

Case  5 

Diagnosis.  Manic  depressive  insanity,  circular  type. 

F.  H.  Mother  insane;  maternal  aunt  in  state  hospital  for 

the  insane. 

P.  H.  Male;   age  36;  born  in  Austria;  U.  S.    11  years; 

carpenter ;  married ;  wife  and  five  children. 

Psychosis.  Patient  had  been  home  for  one  month  and  was  in- 

active, melancholy,  shunned  company.  At  first  visit  to 
clinic  spoke  in  a  random  manner ;  showed  poor  orien- 
tation as  to  time ;  appeared  confused ;  complained  of 
head  being  mixed  up ;  in  a  hypomanic  state. 

Method 

Mental.  At   first   examination   at   clinic  psychiatrist  recom- 

mended commitment  to  a  state  hospital  and  same  was 
arranged  by  worker.  Remained  in  the  hospital  for 
seven  weeks.  On  discharge  condition  was  much  im- 
proved with  prospect  of  ultimate  recovery.  Returned 
to  clinic  after  discharge  and  found  to  be  in  a  hypo- 
manic  state.  Examined  and  treated  at  clinic  for  16 
months,  patient  coming  very  regularly.  Worker  visited 
patient  frequently  at  his  home. 

Physical.  No  physical  needs  were  discovered  that  needed  at- 

tention. 


202     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [344 


Social.  Family  provided  with  rent,  living  expenses,  clothing, 

etc.  during  the  time  that  patient  was  in  the  state  hos- 
pital. Adjusted  economically  during  hospital  resi- 
dence and  after  discharge.  Financial  sources  of  worry 
and  distress  removed,  as  these  seemed  to  be  important 
contributing  causes  to  illness  of  patient. 

Recreational.       Advised. 

Result 
Patient  made  full  recovery;  returned  to  work  and 
earned  sufficient  property  to  support  self  and  family. 
No  relapse  after  several  years. 


Diagnosis. 
F.  H. 
P.  H. 

Psychosis, 


Mental. 

Physical. 
Social. 


Case  6 

Manic  depressive  insanity,  circular  type. 

Unascertained. 

Female;  age  28 ;  born  in  Roumania;  U.  S.  15  years; 
housework;  married;  husband  and  four  children. 

Patient  admitted  to  psychopathic  ward  in  depressed, 
irritable,  hyperactive  condition.  Husband  refused  to 
sign  commitment  papers;  patient  discharged  to  his 
custody  in  hypomanic  state.  Similar  attack  five  years 
previous  following  confinement.  In  a  few  days  hus- 
band returned  patient  to  psychopathic  ward;  com- 
mitted ;  remained  five  months  in  state  hospital  and 
discharged  after  showing  a  slight  improvement.  Three 
months  later  relapsed ;  returned  to  state  hospital  for 
seven  months;  discharged  improved.  Shortly  there- 
after came  to  mental  hygiene  clinic. 

Method 

Examined  and  advised  regularly  at  clinic  by  physi- 
cian and  at  home  by  worker.  Examined  regularly  and 
watched  carefully  for  several  months  prior  to  and 
following  last  confinement. 

Arranged  for  confinement ;  needs  of  patient  and 
children  attended  to  at  clinic  and  dispensaries. 

Cared  for  children  in  a  boarding  home  following 
discharge  of  patient  from  state  hospital,  when  patient 
first  came  under  care  of  mental  hygiene  agency. 
Source  of  stress  thus  removed  for  a  period  of  several 


345] 


SOCIAL  TREATMENT  OF  INSANE 


203 


months,  during  which  time  patient  recuperated.    Hus- 
band enabled  to  obtain  better  and  more  lucrative  em- 
ployment.     Family  moved   into  better  quarters,   this 
resulting  in  improvement  of  all  members  of  family. 
Recreational.      Advised  and  helped  to  carry  out  plans. 

Result 

Patient  made  full  recovery  and  suffered  no  relapse 
within  two  years  after  last  confinement. 

Case  7 

Diagnosis.         Allied  to  manic  depressive  insanity. 

F.  H.  Negative. 

P-  H.  Female ;  age  19  ;  bora   in  Russia ;   U.  S.  2  years ; 

operator;  single. 

Psychosis.  Two   months   prior   to   admission    to    psychopathic 

ward  patient  became  weak  and  fainted.  Remained  in 
bed ;  did  not  speak ;  stated  she  was  weak  and  could 
not  work ;  at  times  cried ;  no  hallucinations ;  no  delu- 
sions ;  showed  some  depression  and  irritability.  Cause 
of  illness  as  stated  by  relatives  was  that  a  younger 
sister  married  a  man  with  whom  patient  was  in  love. 

Method 

Mental.  Patient  was  taken  from  the  psychopathic  ward  and 

sent  to  a  private  sanatorium  where  she  remained  for 
four  weeks.  Left  before  making  a  full  recovery,  re- 
fusing to  remain  among  "  crazy  "  people.  Afterwards 
was  brought  to  clinic  regularly,  examined  and  advised. 
Home  frequently  visited  by  worker. 

Physical.  Advised  at  clinic  regarding  constipation  and  cardiac 

palpitation. 

Social.  Assisted  financially;  interested  in  a  settlement  class. 

Recreational.      Stimulated  interest  in  theatres  and  social  affairs. 

Result 
Patient  improved  rapidly  and  soon  returned  to  for- 
mer employment.  Feeling  well  two  years  after  being 
discharged  from  further  supervision  and  care.  Patient 
became  adjusted  to  home  conditions,  as  well  as  to  life 
in  a  metropolis. 


204 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[346 


Diagnosis. 
F.  H. 
P.  H. 

Psychosis. 


Mental. 


Case  8 

Allied  to  manic  depressive  insanity. 

Negative. 

Female ;  age  42  ;  born  in  Roumania;  U.  S.  10  years; 
housework ;  husband  and  iive  children. 

At  iirst  visit  to  clinic,  patient  complained  of  insom- 
nia ;  was  excitable ;  accused  husband  of  going  out  with 
other  women;  no  basis  for  this  complaint.  Also  ac- 
cused her  mother  of  personal  antagonism.  Could  not 
do  housework ;  showed  no  interest  in  her  children. 
Threatened  to  commit  suicide  on  several  occasions. 
About  ten  similar  attacks  in  fifteen  years. 

Method 


at  reguiar  in- 
interest  in  her 


Patient  induced  to  come  to  clinic  regularly  where 
physician  examined  and  advised  her.  Worker  at  first 
visited  the  patient  several  times  a  week  and  helped  her 
to  make  necessary  mental  adjustments.  Later,  as  she 
showed  improvement,  she  was  visited 
tervals  and  stimulated  to  take  a  wider 
home  and  family. 

Physical.  Examined  at  clinic  and  advised. 

Social.  Patient   was   very    unsystematic    in    her    household 

work,  and  since  her  marriage  had  never  learned  how 
properly  to  care  for  home  and  children.  Regular  and 
frequent  visits  of  worker  who  taught  her  these  things 
helped  materially.    Attended  to  needs  of  children. 

Recreational.      Could  only  advise.     Had  not  learned  nor  ever  ap- 
preciated the  value  of  proper  kind  of  recreation. 

Result 

Patient  had  improved  very  much  when  supervision 
was  ended.  Has  continued  at  this  level  for  a  nimiber 
of  years,  and  stated  that  the  mental  hygiene  agency 
has  aided  her  more  properly  to  understand  herself. 

Case  9 

Diagnosis.         Allied  to  manic  depressive  insanity. 

F.  H.  Negative. 

P.  H.  Female;  age  14 ;  born  in  U.  S. ;  public  school  pupil. 


347] 


SOCIAL  TREATMENT  OF  INSANE 


205 


Psychosis.  Following  the  extraction  of  some  teeth,  patient  be- 

came somewhat  confused ;  remained  in  bed  for  a 
month,  after  which  she  showed  a  little  improvement. 
Within  a  month  again  became  confused,  irritable, 
talked  of  people  following  her  about  and  speaking  ill 
of  her ;  very  fidgety ;  shortly  thereafter  could  not  talk 
nor  use  hands.  Parents  brought  her  to  psychopathic 
ward  and  in  a  few  days  she  was  committed  and  sent 
to  a  state  hospital,  where  she  remained  for  three 
weeks  and  discharged  in  an  improved  condition. 

Method 

Mental.  After  discharge  from  state  hospital  was  brought  to 

clinic  and  examined  by  physician.  Patient  found  to 
have  improved  very  much  and  return  to  school  advised. 
Came  to  clinic  several  times,  being  examined  and  ad- 
vised.    Visited  frequently  by  worker. 

Physical.  Sent   to   summer   camp   for   adolescent   girls   main- 

tained by  agency;  remained  there  several  weeks  until 
she  was  in  good  physical  condition. 

Social.  Family  moved  to  better  neighborhood  ;  parents  were 

aged  and  did  not  understand  the  patient  and  her 
needs.  Worker  helped  to  adjust  the  patient  to  her 
parents  and  to  give  them  another  point  of  view  re- 
garding their  daughter.  By  visiting  school  teachers, 
worker  brought  about  a  better  understanding  of  patient 
by  teachers. 

Recreational.      Patient  taken  to  a  settlement  and  interested  in  a 
club  and  in  other  activities. 

Result 

Patient  improved  very  much  physically;  recovered 
mentally;  no  relapse  within  two  years  after  being 
taken  under  care. 


dementia  praecox 
Case  10 


Diagniosis.  Dementia  praecox,  simple. 

F.  H,  Negative,  except  for  a  brother  who  is  nervous  and 

very  irritable. 


2o6     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [^^^g 

^-  H.  Male;   age  24;   bom   in   Russia;   U.  S.    18  years; 

graduated  public  school  at  14  years;  attended  eve- 
ning high  school  two  years;  clerical  worker,  helper  in 
restaurants,  odd  jobs ;  single. 

Psychosis.  Patient  first  complained  of  being  ill  five  years  be- 

fore coming  to  clinic;  had  many  jobs  since  then  but 
could  not  hold  one  for  any  length  of  time,  being 
either  discharged  or  leaving  of  own  accord.  At  first 
visit  to  clinic,  complained  of  inability  to  get  along 
with  people,  because  they  passed  remarks  about  him 
indirectly ;  attitude  and  manner  somewhat  constrained ; 
gave  expression  to  peculiar  ideas  and  in  discussing  his 
condition  became  quite  rambling  and  involved;  some- 
what evasive  in  answering  questions  and  expressed 
delusional  ideas  of  an  absurd  character.  Also  re- 
ferred to  some  sexual  ideas. 

Method 

Mental.  Given  general  advice  as  to  hygiene  of  mind  during 

visits  to  clinics.  Frequent  and  lengthy  discussions  and 
talks  with  psychiatrist  and  social  worker  seemed  to 
have  a  salutary  effect  upon  patient;  always  left  the 
clinic  in  a  better  and  happier  frame  of  mind  than 
when  he  came. 

Physical.  Patient  suffered  from  some  bladder  trouble  which 

rendered  him  incontinent.  Taken  by  worker  to  special- 
ists for  treatment;  also  to  hospital  where  patient  was 
kept  for  about  a  week.  Condition  complained  of  very 
much  improved,  though  the  ailment  seemed  to  have  its 
origin  in  mental  rather  than  physical  condition  of 
patient.  Remorse  over  earlier  sexual  excesses  and 
masturbation  seemingly  influenced  condition. 

Social.  Due  to  mental   and  physical  condition  of  patient, 

could  not  hold  any  position  for  a  length  of  time; 
helped  him  on  a  number  of  occasions  to  obtain  work 
of  a  suitable  nature,  particularly  light  outdoor  work. 
Did  not  remain  long  in  any  one  job,  though  always 
managed  to  earn  enough  to  be  self-supporting. 
Brought  about  adjustment  between  patient  and  his 
family. 


349] 


SOCIAL  TREATMENT  OF  INSANE 


207 


Recreational.  Advised  and  helped  patient  join  classes  in  gymna- 
sium, for  such  exercise  as  would  be  suitable  to  his 
own  condition.  Advised  as  to  other  forms  of  recrea- 
tion. 

Result 

After  four  years,  mental  condition  of  patient  has 
shown  no  further  deterioration,  though  certain  seem- 
ingly chronic  neurasthenic  symptoms  persist.  Bladder 
condition  somewhat  improved.  Patient  wanders  from 
one  city  to  another,  always  returning  to  New  York 
when  he  is  not  well  and  then  coming  to  clinic.  This 
has  prevented  continuous,  constructive  work  for  any 
length  of  time. 


Diagnosis. 
F.  H. 


P.  H. 


Psychosis. 


Mental. 


Case  11 

Dementia  praecox,  hebephrenic  form. 

Father  somewhat  peculiar  in  his  actions  and  highly 
nervous;  mother  dull;  older  brother  patient  in  a 
state  hospital  with  a  diagnosis  of  dementia  praecox, 
hebephrenic  type. 

Male;  age  20;  born  in  Russia;  U.  S.  10  years;  did 
not  graduate  from  public  school;  helper  and  odd 
jobs;  single. 

Patient  complained  of  as  being  very  lazy;  worked 
at  irregular  intervals  in  many  different  positions  since 
the  age  of  14  years.  Enlisted  in  army  at  18  years 
and  discharged  within  ten  weeks  because  of  mental 
condition.  Acted  peculiarly  in  a  restaurant,  was  ar- 
rested, and  sent  to  psychopathic  ward  for  observation. 
Mother  refused  to  sign  commitment  papers  and  pa- 
tient was  discharged  to  her  custody.  Very  difficult  to 
manage  and  get  along  with  at  home;  unruly;  threat- 
ening bodily  violence  to  members  of  family. 

Method 

After  discharge  from  psychopathic  ward,  referred 
to  mental  hygiene  agency.  At  first  visit  given  thor- 
ough mental  examination  and  found  to  be  a  badly 
deteriorated  case.  Patient  expressed  desire  to  enter  a 
state  hospital ;  worker  at  clinic  arranged  for  his  vol- 


2o8     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[350 


Physical. 


Social. 


Recreational 


untary  commitment,  as  he  refused  and  mother  would 
not  accede  to  a  regular  commitment  through  psycho- 
pathic ward.  Discharged  from  state  hospital  at  own 
request  at  end  of  ten  days.  Mother  again  refused  to 
have  him  committed,  though  father  was  quite  willing 
to  have  that  done.  Very  troublesome  and  pugnacious 
while  in  state  hospital. 

Thorough  physical  examination  at  clinic  revealed 
no  physical  defects  needing  treatment. 

Obtained  several  positions  for  patient  both  in  coun- 
try on  a  farm  and  in  the  city.  Had  difficulties  with 
fellow  workers  and  employers  in  every  place.  Usually 
discharged  within  a  day.  This  so  discouraged  him 
that  he  later  refused  to  look  for  work  or  report  when 
work  was  found  for  him ;  preferred  to  loaf  in  street 
and  around  house. 

Very  difficult  to  advise  because  of  negativistic  atti- 
tude, as  well  as  hostility  to  all  doctors  and  mental 
hygiene  workers. 


Diagnosis. 

F.  H. 
P.  H. 


Result 

Very  little  could  be  accomplished  with  a  patient  in 
this  condition.  Patient  smashed  windows  with  stones 
in  home  of  head  of  organization.  Next  day  sent  regis- 
tered letter  threatening  life  of  worker  unless  sum  of 
$2,500  was  given  by  worker  to  patient  within  two 
days.  When  arrested  at  his  home  a  heavy  slung-shot 
was  found  in  his  pocket.  At  police  station  stated  he 
intended  to  kill  worker  unless  money  was  given  him 
within  specified  time.  A  commission  found  him  insane 
and  he  was  sent  to  state  hospital  for  criminally  insane. 
No  improvement  after  one  year  residence  there. 

Case  12 

Dementia  praecox,  hebephrenic  form.  Constitu- 
tional psychopath. 

Negative. 

Male ;  age  20 ;  bom  in  U.  S. ;  helper  in  dental 
office;  high  school  2  years;  single. 


351] 

Psychosis. 


SOCIAL  TREATMENT  OF  INSANE 


209 


Mental. 


Physical. 


Social. 


Patient  always  quiet  and  seclusive ;  rather  studious 
and  never  cared  to  associate  with  boys.  Left  high 
school  at  age  of  16  years,  when  he  complained  of 
being  ill  and  unable  further  to  continue  his  studies; 
stated  his  heart  pained  him  and  that  he  felt  a  choking 
sensation  in  his  throat.  Since  then  he  beccune  more 
seclusive,  timid,  and  shunned  company  of  others. 
Occasionally  became  excited  and  would  quarrel  with 
sisters.  Taken  to  psychopathic  ward  by  father,  where 
he  showed  all  the  above  symptoms.  Had  no  delu- 
sions or  hallucinations,  and  no  suicidal  ideas.  Father 
refused  to  sign  commitment  papers  and  took  patient 
home. 

Method 

Directly  after  discharge  from  psychopathic  ward  re- 
feiTed  to  mental  hygiene  clinic.  During  period  of  six 
years  that  patient  was  under  care  he  came  to  clinic  at 
regular  intervals  to  see  physician  for  examination  and 
advice.  Though  fearful  of  all  physicians  because  of 
having  been  in  psychopathic  ward,  he  developed  much 
confidence  in  physicians  who  treated  him  at  clinics, 
,as  he  came  to  feel  that  his  condition  was  understood 
and  received  sympathetic  consideration.  Advised  reg- 
ularly both  by  physicians  and  by  workers. 

Came  to  clinic  whenever  he  had  some  physical  ail- 
ment that  needed  attention  and  could  be  prescribed  for 
at  clinic.  Referred  and  taken  to  different  hospitals 
and  dispensaries  whenever  need  arose. 

Patient  unable  to  find  work  at  which  he  could  re- 
main any  length  of  time.  Expressed  desire  to  learn  a 
trade,  preferably  mechanical  dentistry;  sent  to  a 
school,  where  he  became  proficient  at  his  work.  Or- 
ganization paid  for  course  and  incidental  expenses. 
Aided  occasionally  with  living  expenses  and  clothing. 
Position  as  mechanical  dentist  obtained  for  him ;  after 
becoming  proficient  able  to  earn  $25.00  per  week. 
Inability  to  earn  more  due  to  shaking  of  hands. 
When  work  in  his  line  was  slow,  obtained  other  em- 
ployment for  him. 


2IO     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[352 


Recreational.  Patient  advised  by  physician  and  worker  as  to  kind 
of  recreation  best  suited  to  his  needs.  Taken  out  for 
walks ;  interested  a  college  student  in  him ;  helped  to 
plan  spare-time  activities. 

Result 

For  several  years  patient  has  been  able  to  take  care 
of  self  financially;  has  not  found  it  necessary  to  re- 
turn to  psychopathic  ward  nor  to  enter  a  state  hospital. 
Is  no  longer  fearful  of  people,  particularly  of  police 
as  formerly;  goes  alone  to  theatres,  parks,  etc.  Still 
nervous  but  now  understands  his  condition  and  knows 
what  to  do  when  he  is  not  feeling  well,  having  been 
advised  at  clinic. 


Diagnosis. 
F.  H. 


P.  H. 


Psychosis. 


Mental. 


Case  13 

Dementia  praecox,  katatonic  form. 

Father  in  state  hospital  for  insane;  diagnosis,  or- 
ganic nervous  disease.  Paternal  aunt  committed  sui- 
cide while  depressed. 

Male ;  age  22  ;  bom  in  U.  S. ;  stock  clerk ;  public 
school  graduate;  single. 

A  few  weeks  prior  to  being  brought  to  psychopathic 
ward  patient  became  quite  nervous  and  gave  vent  to 
undue  excitement.  During  the  previous  election  period 
became  engaged  in  many  heated  arguments  and  worked 
himself  into  a  highly  nervous  state,  resulting  in 
sleeplessness  and  marked  loss  of  appetite.  Also  wor- 
ried about  being  drafted  and  became  distressed  because 
he  feared  he  was  losing  his  health.  Began  to  hear 
imaginary  voices ;  became  much  depressed ;  could  not 
eat  or  sleep ;  refused  to  speak  to  anyone,  feared  to 
meet  strangers.  Preferred  to  sit  in  a  comer  or  in  a 
room  by  himself,  usually  without  changing  his  posture 
for  hours  at  a  time. 

Method 

Parents  refused  to  sign  commitment  papers  and 
took  patient  home.  Then  sent  him  to  a  private  sana- 
torium for  two  months  where  he  showed  little,  if  any, 


353] 


SOCIAL  TREATMENT  OF  INSANE  21 1 


improvement.     Social   worker  advised   taking   patient 
home,  particularly  since  family  had  to  borrow  money 
to  pay  for  care  of  patient.    Upon  return  home  brought 
•  '  to  clinic  for  examination,  but  little  could  be  accom- 

plished as  patient  refused  to  answer  questions  of  ex- 
amining physician,  and  did  not  speak  at  all.     Worker 
''•\  called  at   home  of  patient  regularly  and  after  many 

-  .^  efforts  induced  patient  to  go  out  for  walks  with  him. 

This  seemed  to  help  very  much;  parents  then  had 
someone  take  him  out  daily  for  long  walks  in  nearby 
park  and  to  other  places  about  the  city.  Gradually 
began  to  talk,  to  eat  regularly,  and  to  look  after  clothes, 
etc.  Family  advised  as  to  how  best  to  get  along  with 
patient.  In  two  months  latter  began  to  talk  to  worker 
and  to  receive  him  more  cordially  than  had  formerly 
been  the  case.  At  end  of  four  months  patient  began 
to  speak  freely  to  all,  though  refusing  to  account  for 
previous  behavior. 

Physical.  No  physical  needs  discovered  that  needed  attention. 

Social.  No  need,   except  to  advise  family  regarding  com- 

mitment of  father  of  patient. 

Recreational.       Advised. 

Rendt 

Patient  found  work  by  himself  and  has  continued 
in  one  position  for  nearly  two  years.  Seems  fully  re- 
covered; earning  higher  wages  than  previous  to  ill- 
ness ;  sociability  has  become  normal. 

Case  14 

Diagnosis.  Dementia  praecox,  paranoid  form. 

F.  H.  Sister  acted  in  a  strange  and  peculiar  manner  for  a 

nmnber  of  years;  later  committed  suicide. 

P.  H.  Male;  age  43 ;  born  in  Russia;  U.  S.  21  years ;  shoe 

operator;  married;  wife  and  six  children. 

Psychosis.  Patient  referred  to  clinic  by  another  organization. 

At  first  clinic  examination,  talked  very  profusely  and 
volubly  about  his  domestic  difficulties;  stated  his 
troubles  began  when  he  married,  because  his  wife  is 
smarter  than  he  is;  also,  that  his  wife  has  always 
%  been  and  still  is  unfaithful;  that  the  youngest  child 


212     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[354 


of  the  family  is  not  his  own.  Could  not  tell  his  story 
connectedly;  stuttered  and  it  was  very  difficult  to  fol- 
low him;  admitted  he  was  very  nervous.  Trouble- 
some and  abusive  at  home ;  used  vile  language  to  wife 
and  children ;  threatened  bodily  harm  to  wife ;  very 
easily  influenced  by  opinions  of  friends  and  relatives, 
to  whom  he  spoke  openly  of  the  supposed  infidelity 
of  his  wife. 

Metko(/ 

Mental.  Patient  induced  to  come  to  clinic  after  a  number  of 

visits  to  home  and  much  persuasion.  Insisted  there 
was  nothing  the  matter  with  him  mentally.  Subse- 
quently visited  clinic  on  several  occasions;  physician 
and  worker  helped  to  straighten  out  and  explain  away 
some  of  his  mental  difficulties  and  doubts,  and  to 
bring  about  a  better  understanding  between  patient 
and  his  family. 

Physical.  Arranged  for  treatment  of  heart  condition  of  which 

patient  complained;  examined  at  clinic  and  treatment 
prescribed  for  minor  ills.  Several  children  and  wife 
suffering  with  various  physical  ills;  treatment  at  hos- 
pitals arranged  for;  convalescent  care  provided  for 
children. 

Social.  Patient  at  first  did  not  make  sufficient  allotment  to 

family  out  of  his  earnings.  Due  to  this  and  difficulty 
he  caused  at  home,  wife  agreed  to  have  him  sum- 
moned to  Domestic  Relations  Court  on  charge  of  non- 
support,  as  patient  would  not  heed  advice  given  him 
by  worker.  Latter  went  to  court  with  wife,  and  upon 
presentation  of  facts  by  worker,  judge  ordered  a  fifty 
per  cent  increase  in  allowance  and  also  that  patient 
must  live  away  from  home.  This  arrangement  helped 
matters  greatly  for  family;  for  first  time  in  many 
years  patient  made  to  realize  his  responsibility  to  fam- 
ily; begged  wife  to  be  permitted  to  return  home, 
promising  to  behave,  not  to  accuse  her  of  infidelity, 
and  to  give  her  all  his  earnings.  After  several  months' 
absence  from  home,  for  sake  of  smaller  children,  wife 
advised  to  permit  patient  to  come  home.    Employment 


355] 


SOCIAL  TREATMENT  OF  INSANE 


213 


obtained  for  oldest  son ;  family  aided  with  rent,  living 
expenses,  clothing,  when  patient  did  not  or  could  not 
provide  same  for  family. 
Recreational.      No  cooperation  on  part  of  patient.      Preferred  to 
spend  spare  time  at  home  with  children. 

Result 

One  year  after  patient  returned  home,  conducting 
self  more  properly  and  no  longer  abuses  wife  and 
children.  Has  acknowledged  that  baby  he  formerly 
disowned,  was  his  own  child  and  that  it  resembled  its 
paternal  grandmother.  Family  able  to  support  self 
through  earnings  of  children  and  contributions  of 
patient.  Latter  has  become  readjusted  to  home  and 
family.  Questionable  whether  he  has  rid  himself  of 
idea  that  wife  was  unfaithful. 


Case  15 

Diagnosis.         Allied  to  dementia  praecox. 

F.  H.  Father  died  from  apoplexy;  mother  died  in  thir- 

teenth confinement,  in  convulsions. 

P.  H.  Female;  age  21;  bom  in  Russia;  U.  S.  2  years; 

housework;  saleswoman  before  marriage;  child  one 
year  old. 

Psychosis.  Patient  developed  pneumonia,   taken   to   a   general 

hospital  and  remained  there  four  weeks.  Thence 
transferred  to  psychopathic  ward.  Refused  to  take 
food  and  medication;  recognized  no  one;  crawled  in 
bed  and  hid  under  covers  when  anyone  came  near  her ; 
scratched  and  attempted  to  bite  nurses;  sat  in  bed 
rocking  back  and  forth,  moaning  all  the  while.  De- 
pressed and  refused  to  talk,  sometimes  lying  in  a  very 
rigid  position.  Recovered  sufficiently  within  four  days 
to  be  permitted  to  go  home  with  husband,  who  refused 
to  sign  conmiitment  papers. 

Method 

Mental.  Family   visited    shortly   after  discharge  of   patient 

from  psychopathic  ward.  After  many  visits,  patient 
induced  to  come  to  clinic,  where  she  was  found  to  be 


214     ^^^^^^^  ASPECTS  OF  TREATMENT  OF  INSANE     [356 

dull  and  inactive,  manifesting  very  little  initiative. 
Did  not  recognize  physician,  who  had  also  treated  her 
in  the  psychopathic  ward.  Several  visits  a  week  to 
home  by  social  worker  and  regular  visits  to  clinic  for 
examination  and  advice  by  physician,  helped  to  stim- 
ulate patient  to  care  for  home  and  baby,  to  become 
more  sociable,  etc.  Patient  refused  to  enter  a  private 
sanatorium  when  worker  offered  to  send  her  there,  as 
she  did  not  want  to  leave  her  child. 

Physical.  Obtained   necessary   dental    work    for    patient    and 

agency  paid  for  same.  Gave  birth  to  a  baby  while 
under  care ;  arranged  for  necessary  care  of  patient  and 
children. 

Social.  Husband  a  house  painter  with  short  seasonal  em- 

ployment. Moved  family  into  better  and  cleaner 
quarters,  near  home  of  an  aunt  who  had  promised  to 
help  look  after  patient.  Supplied  living  expenses  and 
rent  whenever  necessary,  clothing,  etc.  Taught  patient 
how  to  keep  her  house  clean,  how  properly  to  prepare 
and  serve  meals.  Aided  brother  who  lived  with  pa- 
tient to  enter  a  trade  school  and  to  obtain  employment. 

Recreational.  Advised  regarding  kind  of  outdoor  exercise  to  take; 
worker  took  patient  for  walks.  Instructed  in  proper 
kinds  of  recreation. 

Result 

Patient  under  care  for  six  years.  During  all  this 
time  it  was  never  necessary  for  her  to  return  to 
psychopathic  ward  or  to  go  to  any  other  institution 
because  of  mental  relapse.  Became  much  brighter, 
showed  more  initiative,  talked  more  fluently;  in  gen- 
eral, learned  to  take  a  better  view  of  life,  and  to  ex- 
hibit good  insight  into  her  condition.  Economically 
adjusted  when  husband  obtained  regular  employment. 

paranoid  condition 

Case  16 

Diagptiosis.  Paranoid  condition. 

F-  H.  Unascertained. 


357] 


SOCIAL  TREATMENT  OF  INSANE 


215 


P.  H.  Male;  age   56;   born  in  Russia;  U.   S.  35  years; 

cashier  in  restaurant ;  married  second  time ;  first  wife 
died;  adult  daughter  of  first  marriage;  daughter  10 
years  of  second  marriage. 

Psychosis.  Patient  became  excited  while  walking  in  street  and 

brought  to  psychopathic  ward.  Stated  he  worked  as 
night  cashier  in  restaurants  for  over  25  years;  never 
had  any  free  time ;  for  a  nmnber  of  years  he  was 
being  followed  about ;  strangers  threatened  to  kill 
him;  called  him  vile  names;  pointed  him  out  to 
others,  cursing  him  and  saying,  "  There  he  goes — 
that  man  is  no  good."  Thought  there  must  be  some 
society  interested  in  ruining  and  killing  him.  Later 
feared  to  go  to  work;  remained  at  home  and  would 
not  even  go  down  stairs  to  stoop  of  house,  because  he 
believed  he  was  always  being  watched.  Wife  refused 
to  sign  commitment  papers  and  patient  discharged  to 
her  custody. 

Method 

Mental.  After  discharge  from  psychopathic  ward  referred  to 

mental  hygiene  agency.  Came  to  clinic  several  times, 
but  would  not  talk  to  physician  unless  social  worker 
left  the  room,  as  he  feared  latter  might  be  a  detective 
or  a  member  of  a  secret  society  interested  in  harming 
him.  Later  became  convinced  this  was  not  so.  Very 
little  could  be  done  with  patient  at  clinic  as  he  feared 
to  speak  to  physician  of  his  troubles. 

Physical.  Complained  of  severe  rheumatic  pains  all  over  body 

and  particularly  in  legs.  Patient  very  anxious  to  enter 
some  hospital  for  treatment,  provided  he  could  be 
convinced  that  institution  to  which  he  would  go  was 
not  one  for  the  insane.  Worker  arranged  for  treat- 
ment in  a  general  hospital.  Patient  left  there  because 
of  poor  food,  and  decided  to  remain  at  home  there- 
after. Wife  of  patient  complained  of  various  ailments 
and  treatment  arranged. 

Social.  Obtained  several  light  positions  for  patient ;  helped 

family  financially.  When  patient  insisted  on  remain- 
ing at  home  and  refused  to  go  out  to  work  because  he 
feared  he  was  being  followed,  arranged  for  wife,  who 


2i6     SOCIAL  ASPECTS  OF  TREATMENT  OF  JNSANE     [358 

could  sew,   to  take  work   home  and   to   have  patient 
help  her. 
Recreational.      No  provision  could  be  made ;  no  cooperation. 

Result 

Plan  of  having  patient  remain  at  home  and  help 
wife  has  worked  out  successfully  for  about  two  years. 
No  longer  so  fearful  as  formerly,  due  to  exciting 
causes,  namely,  contact  with  strangers,  having  been 
removed.  Family  able  to  get  along  without  financial 
assistance,  though  patient  has  by  no  means  recovered. 
He  has  merely  been  somewhat  readjusted. 


Diagnosis. 
F.  H. 
P.  H. 


Psychosis. 


Mental. 


Case  17 

Paranoid  condition. 

Unascertained. 

Female;  age  33;  bom  in  Russia;  U.  S.  14  years; 
housework ;  deserted  by  husband ;  three  minor  chil- 
dren. 

Patient  referred  to  clinic  by  hospital  social  service. 
Found  to  have  been  queer,  nervous  and  quarrelsome 
since  childhood ;  neglected  her  children  and  home. 
At  clinic  stated  gangsters  followed  her  and  called  her 
vile  names ;  had  complained  to  police  of  supposed 
persecution  by  "  Black  Hand  "  and  others.  Moved 
from  place  to  place  to  avoid  persecutors;  suspicious 
that  husband  was  in  league  with  her  enemies. 

Method 

Patient  had  been  sent  to  psychopathic  ward  by  De- 
partment of  Public  Charities,  where  she  had  gone  to 
complain  of  persecution.  Relatives  refused  to  sign 
commitment  papers  and  patient  was  discharged  to 
their  custody.  Worker  followed-up  patient  after  dis- 
charge and  succeeded  in  having  her  come  to  clinic, 
where  she  repeated  her  story  of  persecution.  In  five 
months  did  not  come  to  clinic  more  than  twice ;  fol- 
lowed by  worker  from  one  address  to  another  for 
period  of  seven  months.  No  cooperation  either  in 
clinic  or  at  home. 


359] 


SOCIAL  TREATMENT  OF  INSANE 


217 


Physical.  No  cooperation. 

Social.  Helped  to  have  children  committed  to  an   orphan 

asylum  after  relatives  could   no  longer  do  anj^hing 

with  patient. 
Recreational.      No  cooperation. 

Result 

Relatives  had  patient  committed  to  a  state  hospital. 
Mental  hygiene  agency  could  not  get  patient  to  co- 
operate in  the  least. 

Case  18 

Diagnosis.         Paranoid  condition. 

F.  H.  Mother  "  nervous  ". 

P.  H.  Male;   age  42;  bom  in  Austria;  U.  S.    16  years; 

clothing  presser;  married;  wife  and  four  children. 

Psychosis.  Wife  had  patient  arrested  for  non-support;   judge 

in  Domestic  Relations  Court  sent  patient  to  psycho- 
pathic ward  for  observation.  Wife  stated  that  patient 
was  always  of  an  obstinate  disposition  but  showed  no 
definite  mental  symptoms  until  about  one  year  previous 
to  hospital  admission.  Then  began  to  complain  of 
various  pains  over  his  entire  body ;  worked  very  irreg- 
ularly during  this  time;  stated  people  were  annoying 
him;  that  they  talked  about  him;  said  everyone  was 
his  enemy.  At  times  became  noisy  and  excited  and 
made  threats  to  kill  his  wife,  whom,  in  presence  of 
children,  relatives  and  friends,  he  accused  of  miscon- 
duct with  various  men.  Very  vile  in  his  language  to 
wife  and  adult  daughter ;  religiously  fanatical.  Wife 
refused  to  sign  commitment  papers  and  patient  was 
discharged  on  contract  to  her  custody. 

Method 

Mental.  Following  discharge  from  psychopathic  ward  patient 

was  followed  up  and  induced  to  come  to  clinic.  Came 
only  twice,  as  he  feared  physician  and  worker  were  in 
league  with  others  to  do  him  harm.  Wife  of  patient 
endured  his  abuse  for  over  a  year  after  taking  him 
from  ward,  and  then  asked  worker  to  help  her  to  have 


2i8     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [360 

patient  arrested  on  charge  of  non-support,  as  he  had 
threatened  to  kill  wife  and  children  and  they  lived  in 
fear  of  him.  At  court,  after  much  difficulty  due  to 
refusal  of  judge  to  believe  anything  was  wrong  with 
patient  mentally,  he  was  again  sent  to  psychopathic 
ward  for  observation.  Committed  to  a  state  hospital 
where  he  remained  for  nine  months.  Upon  being 
paroled,  reported  regularly  to  state  hospital  clinic, 
fearing  he  would  be  recommitted  unless  he  did  so. 
Attitude  toward  family  changed  and  improved  first 
month  or  two  following  home-coming. 

Physical.  Patient  in   good  physical   condition ;   arranged  for 

treatment  of  certain  physical  ills  of  wife. 

Social.  Worker   attempted   on   several   occasions    to   obtain 

work  for  patient,  but  he  refused  proffered  help.  Ob- 
tained work  by  himself,  and  although  wage  offered 
was  less  than  half  the  standard  wage  as  set  by  union, 
patient  refused  to  accept  more  than  half  of  what  was 
offered  him,  giving  as  an  explanation  that  he  did  not 
need  more  for  his  personal  wants.  Worker  went  to  see 
employer  and  arranged  that  balance  of  wages  be  sent 
direct  to  wife  without  patient  being  aware  of  this 
arrangement.  Offered  to  advance  patient  money  neces- 
sary to  reinstate  him  in  his  union,  but  he  refused  offer. 
Family  advised  regarding  various  problems  involved 
in  dealing  with  patient. 

Recreational.      No  cooperation  from  patient. 

Result 

Patient  has  shown  but  little  improvement  during 
two  years  he  has  been  known  to  agency.  No  longer 
strikes  wife  and  does  not  threaten  to  kill  her,  as  he 
knows  wife  can  and  does  come  to  agency  and  worker 
to  help  in  dealing  with  him.  Feels  that  if  he  mis- 
behaves as  formerly  wife  will  have  him  rearrested  and 
returned  to  state  hospital.  Family  now  have  a  better 
understanding  as  to  how  to  deal  with  patient  and  have 
,  readjusted  themselves  to  the  needs  of  the  situaticMi. 


36i] 


SOCIAL  TREATMENT  OF  INSANE 


219 


Diagnosis. 
F.  H. 
P.  H. 

Psychosis. 


Mental. 


Physical. 


Social. 


general  paralysis 
Case  19 

General  paralysis. 

Negative. 

Male;  age  42;  born  in  Russia;  U.  S.  15  years; 
watchmaker ;  married ;  wife  and  four  children. 

Patient  admitted  a  specific  infection  at  age  of  18 
years ;  three  years  later  complained  of  lightening  pains 
in  legs  and  body.  At  age  of  41  years  remained  out 
of  work  for  several  months  due  to  numerous  somatic 
complaints.  For  a  year  had  been  more  nervous  and 
irritable  than  formerly,  and  had  failed  physically; 
complained  of  pains  in  region  of  heart  and  of  general 
weariness ;  had  no  ambition  to  work  and  was  depressed 
because  hands  were  so  tremulous  that  he  could  not 
hold  a  position.  Taken  to  psychopathic  ward  and 
committed  to  a  state  hospital ;  there  two  months  and 
paroled. 

Method 


Referred  to  clinic  after  discharge  from  state  hos- 
pital, examined  and  advised  regarding  further  treat- 
ment. Came  to  clinic  thereafter  at  irregular  intervals, 
coming  particularly  when  he  did  not  feel  quite  well. 

Arranged  for  necessary  treatment  of  patient  at  a 
general  hospital.  Wasserman  tests  taken  of  other 
members  of  family  and  found  to  be  negative. 

Aided  family  with  living  expenses  when  necessary. 
Advanced  smn  of  money  to  patient  with  which  to  buy 
a  quantity  of  barber  supplies;  peddled  same  and  for 
a  period  of  five  years  has  managed  to  earn  enough  to 
help  family  become  totally  self-supporting.  Younger 
children  sent  to  summer  camp. 
Recreational.  Advised  at  clinic,  though  patient  felt  he  needed  but 
little  since  he  was  out  in  the  open  most  of  the  day. 

Result 

Patient  has  not  returned  to  a  state  hospital  and  has 
not  deteriorated  mentally,  though  he  has  shown  but 
little  improvement  with  advancing  years. 


220     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[362 


Diagnosis. 
F.  H. 
P.  H. 

Psychosis. 


Mental. 


Physical. 

Social. 

Recreational 


arteriosclerosis 
Case  20 

Arteriosclerosis;  organic  nervous  disease. 

Unascertained. 

Male;  age  63;  bom  in  Russia;  U.  S.  40  years;  no 
occupation;  widower. 

P'or  several  years  patient  disoriented ;  unable  to  give 
age  to  examining  physician;  nor  date  and  place  of 
birth ;  failed  to  recognize  his  children ;  at  times  very 
confused;  became  excited;  wandered  about;  threat- 
ened to  harm  grandchildren. 

Method 

Patient  brought  to  clinic  by  children  for  examina- 
tion and  advice  as  to  what  should  be  done,  as  they 
could  not  care  for  him  because  of  his  mental  condi- 
tion. Advised  to  commit  patient  to  a  state  hospital  as 
the  only  solution  under  the  circiunstances. 


No  need. 


Result 
Patient  committed  to  a  state  hospital  as  was  advised. 


Diagnosis. 
F.  H. 

P.  H. 

Psychosis. 


mental  deficiency 
Case  21 

Mentally  inferior  with  hypomanic  traits. 

Father  queer,  deserted  family  number  of  years  ago; 
mother  paralyzed  in  lower  limbs  for  about  15  years. 

Male;  age  15  ;  bom  in  U.  S. ;  attended  public  school 
in  imgraded  classes. 

Patient  was  a  pupil  in  a  truant  school,  and  was 
sent  to  Children's  Court  by  principal  because  of 
strange  behavior;  got  into  many  fights  with  other 
pupils;  would  bring  knives  and  slugs  to  school  and 
cause  much  trouble.  From  court  sent  to  psychopathic 
ward  for  observation  where  diagnosis  was  made.  Re- 
turned to  school  with  a  reprimand  from  judge. 


3^3] 


SOCIAL  TREATMENT  OF  INSANE 


Method 


221 


Mental.  After  discharge  from  hospital  followed-up  and  in- 

duced to  come  to  clinic.  Stated  that  at  times  he 
heard  voices,  became  dizzy,  was  weak  and  frequently 
fell.  No  history  of  epilepsy  could  be  discovered ; 
patient  was  examined  regularly  at  clinic  and  advised. 

Physical.  Condition  good ;  well-developed  for  his  years ;   no 

serious  ailment  found.  Mother  and  ailing  sister  ad- 
vised. 

Social.  Patient  could  not  get  along  well  with  the  principal 

and  teachers  in  the  school  which  he  attended  last. 
Obtained  transfer  to  another  truant  school  and  did 
very  well  there  during  the  few  months  he  had  to 
attend  till  his  sixteenth  birthday.  Worker  conferred 
with  principals  of  both  schools.  Patient  accounted 
for  his  bad  behavior  by  stating  his  mother  was  very  ill 
and  poor  and  he  wanted  to  go  to  work  to  help  support 
her  and  a  sick  sister;  thought  by  misbehaving  would 
be  given  working  papers  and  discharged  from  school. 
Advised  and  helped  patient  obtain  proper  employ- 
ment; arranged  for  admission  to  a  trade  school. 

Recreational.  Helped  patient  plan  his  evening  and  spare-time  ac- 
tivities ;  joined  athletic  group  in  public  school  center. 

Result 
At  end  of  two  years,  working  regularly  as  helper, 
salary  $20.00  per  week,  all  of  which  he  gives  to  his 
mother.  No  longer  complains  of  hearing  voices;  no 
dizzy  spells.  Hypomanic  condition  cleared  up,  though 
he  is  still  mentally  inferior. 

hysteria 

Case  22 
Diagnosis.  Hysteria. 

F.  H.  Negative. 

P.  H.  Female;  age  33;  bom  in  Russia;  U.  S.  16  years; 

housework   and   embroiderer;    deserted   by   husband; 

one  child. 
Psychosis.  After  a  great  deal  of  trouble  with  her  husband  he 

deserted  her ;  shortly  thereafter  she  suffered  a  physical 


222     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [364 

breakdown.  At  that  time,  /.  e.,  three  years  before 
being  referred  to  mental  hygiene  agency,  doctors  told 
her  she  had  heart  trouble  and  advised  her  not  to  exert 
herself  unduly.  Went  to  bed  and  did  not  rise  for 
three  years,  fearing  she  would  die  if  she  exerted  her- 
self. Taken  to  a  general  hospital,  remained  there  five 
weeks,  transferred  to  psychopathic  ward,  and  taken 
home  next  day  by  relatives. 

Method 

Menial.  After   discharge    from    psychopathic   ward,    patient 

visited  by  mental  hygiene  worker.  Since  patient  could 
not  leave  the  house,  psychiatrist  visited  her  at  home. 
Worker  visited  patient  almost  daily  for  several  months ; 
through  much  coaxing  and  persuasion,  patient  was  in- 
duced to  do  things  she  had  formerly  feared  because  of 
her  supposed  heart  condition;  gotten  out  of  bed  and 
made  to  sit  in  a  chair ;  later  walked  a  few  steps ;  grad- 
ually began  to  dress  and  care  for  self ;  taken  down  to 
street  and  for  automobile  rides  until  she  finally  gained 
sufficient  confidence  in  herself  to  walk  home  from 
where  she  had  been  left,  several  blocks  from  her  home. 

Physical.  Physician  brought  to  patient  for  physical  examina- 

tions ;  taken  to  hospital  for  X-ray  of  lungs,  which  were 
found  to  be  negative  for  tuberculosis,  of  which  there 
had  been  a  suspicion ;  treated  for  her  minor  cardiac 
condition,  both  at  home  and  in  hospital.  Confidence 
restored  in  learning  that  there  was  nothing  seriously 
the  matter  with  her. 

Social.  Family  aided  financially  so  that  patient  might  be 

sent  to  seashore  for  bathing  and  convalescence.  Fam- 
ily educated  in  proper  care  of  patient. 

Recreational.  Walks  with  worker ;  automobile  rides ;  ocean  bath- 
ing. 

Result 

After  being  under  care  for  one  year,  patient  entirely 
recovered    mentally    and    much    improved    physically. 
Members  of  family  and  neighbors  think  a  miracle  was 
'  '•':  achieved. 


365] 


SOCIAL  TREATMENT  OF  INSANE 


223 


I 


constitutional  psychopathic  inferiority 
Case  23 

Diagnosis.         Constitutional    psychopathic    inferiority    with    de- 
pressed episodes. 

F.  H.  Negative ;  father  many  years  older  than  mother. 

P.  H.  Female;  age  19;  born  in  Russia;  U.  S.  3  years; 

factory  worker ;  single ;  three  adult  brothers  in  city. 

Psychosis.  Patient  became  depressed  because  of  loss  of  posi- 

tion and  attempted  suicide  by  drinking  carbolic  acid ; 
taken  to  psychopathic  ward ;  remained  there  a  few 
days  and  was  discharged.  Within  a  week  again  at- 
tempted suicide  by  drinking  iodine;  returned  to  psy- 
chopathic ward  and  committed  to  a  state  hospital, 
where  she  was  detained  two  months.  Shortly  after 
discharge,  threatened  on  several  occasions  to  commit 
suicide  and  to  kill  several  persons  known  to  her. 
Often  became  drunk.  Attempts  to  have  her  com- 
mitted again  unsuccessful,  as  brothers  refused  to  sign 
commitment  papers  and  physicians  on  psychopathic 
ward  refused  to  admit  her  unless  papers  were  first 
signed. 

Method 

Mental.  Following    discharge    from    state    hospital    patient 

came  to  clinic  at  irregular  intervals  for  about  four 
years.  Advised  by  physician  about  her  depressions, 
etc.  Social  worker  spent  much  time  with  patient, 
helping  her  over  her  periods  of  depression  and  trying 
to  give  her  a  new  outlook  on  life.  During  examina- 
tion at  clinic  stated,  "  I  heard  voices  when  I  was  in 
the  convalescent  home  because  it  was  very  quiet  there. 
I  was  afraid  to  sleep — I  imagined  I  saw  things  and 
heard  voices  in  my  head.  Sometimes  I  heard  someone 
walking — I  was  afraid  to  be  there — I  was  nervous." 

Physical.  Patient  taken  to  physicians  and  hospitals  for  exam- 

ination and  treatment  of  various  ailments  complained 
of  by  her.  For  a  long  time  insisted  she  had  some 
gynecological  difficulty ;  examinations  by  women  physi- 
cians failed  to  discover  anything.  Sent  to  convalescent 
home  when  rundown  physically. 


224 


SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE 


[366 


Social.  When  patient  was  out  of  work,  home  found  for  her 

and  board  and  incidentals  paid  for  by  agency.  Suit- 
able employment  found  for  patient ;  sent  to  trade 
school ;  given  English  lessons  at  home  by  worker,  as 
patient  complained  that  lack  of  sufficient  knowledge 
of  language  caused  her  much  worry.  Visited  places 
of  employment  and  interested  employers  in  patient. 

Recreational.  Taken  for  walks  to  places  of  amusement;  given 
tickets  to  concerts ;  interested  in  club  work. 

Result 

Despite  all  attempts  of  physician  and  worker  to 
help  patient,  she  persisted  in  drinking,  going  to  cab- 
arets with  chance  acquaintances,  painting,  dressing  in 
a  vulgar  way,  etc.  Worker  could  not  obtain  coopera- 
tion of  brothers  when  it  was  seen  that  she  was  heading 
towards  a  life  of  immorality,  as  they  persistently  re- 
fused to  sign  commitment  papers.  During  periods  of 
depression,  patient  would  come  to  office  of  agency  in  a 
drunken  condition,  create  a  disturbance,  and  threaten 
to  kill  several  of  the  workers.  Admitted  she  was 
leading  an  immoral  life,  but  nothing  could  be  done  by 
worker  to  have  her  committed  because  of  attitude  of 
brothers  and  of  physician  in  psychopathic  ward.  Was 
finally  arrested  for  soliciting  on  the  streets  and  sent 
to  Bedford  Reformatory  for  three  years. 

Case  24 

Diagrnosis.  Constitutional  psychopathic  inferiority  with  epi- 
sodes of  excitement. 

F.  H.  Father  nervous  and  irritable. 

P.  H.  Male;  age  18;  bom  in  U.  S. ;  clerical  worker. 

Psychosis.  For  six  months   prior   to  admission   of   patient   to 

psychopathic  ward,  he  showed  an  inability  to  get  along 
with  his  parents  and  brothers,  with  spells  of  irritabil- 
ity; lacked  efficiency  at  work.  On  ward  was  emo- 
tionally unstable,  with  some  depression ;  had  consider- 
able insight  into  his  condition  which  he  ascribed  to 
excessive  masturbation. 


3^7] 


SOCIAL  TREATMENT  OF  INSANE 


225 


Method 

Mental.  Patient  was  committed  to  a  state  hospital,   as  his 

parents  insisted  they  could  not  cope  with  him.  Re- 
mained in  hospital  for  eight  months,  was  well-behaved 
and  occupied  as  a  messenger  about  the  institution. 
After  discharge  referred  to  clinic;  found  to  have 
improved  while  in  hospital;  advised  regarding  per- 
sonal habits,  etc.  Within  a  few  weeks  parents  returned 
patient  to  hospital  complaining  he  had  again  become 
irritable  and  unable  to  get  along  at  home.  Paroled 
within  a  few  weeks ;  in  about  two  months  returned  to 
hospital  of  own  accord ;  sent  to  city  on  an  errand  and 
failed  to  return  to  hospital.  Came  to  clinic  and 
showed  some  signs  of  improvement,  though  unusually 
talkative.  Returned  to  hospital  of  his  own  accord 
within  a  few  months,  as  he  felt  better  there  than  at 
home.  Though  hospital  physicians  were  willing  to 
discharge  him  within  a  few  weeks  after  last  admission 
and  patient  requested  his  discharge,  parents  refused  to 
take  him  home  until  he  was  in  a  much  better  condition 
mentally. 

Physical.  Prescribed  at  clinic  for  slight  physical  ailment. 

Social.  Obtained  employment  for  patient  when  he  was  out 

on  parole  from  hospital.  Main  effort  was  to  educate 
parents  to  a  proper  understanding  of  the  patient  and 
how  to  care  for  and  treat  him  when  he  was  at  home. 

Recreational.      Advised  regarding  suitable  forms  of  recreation. 

Restelt 

Patient  has  had  to  return  to  and  remain  in  the  state 
hospital  because  of  inability  of  parents  to  understand 
and  care  for  him  during  periods  when  he  was  irri- 
table. Lack  of  cooperation  of  parents  largely  respon- 
sible for  hospital  residence  of  patient.  Poor,  dirty 
home  in  a  crowded  tenement  district  contributing 
factor  to  irritability  of  patient.  Could  not  induce 
parents  to  move  to  a  better  neighborhood  for  sake  of 
patient,  as  father  had  business  interests  which  he  felt 
he  could  not  sacrifice.  Impossible  to  obtain  coopera- 
tion of  parents  to  have  patient  boarded  in  a  better 


226     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [368 

district  and  home.  Necessary  to  wait  until  patient 
becomes  older  and  his  earning  capacity  will  increase 
sufficient  to  render  it  possible  for  him  to  be  entirely 
self-supporting  when  living  away  from  home. 


Diagnosis. 
F.  H. 
P.  H. 


Psychosis. 


Case  25 

Constitutional  psychopathic  inferiority. 

Unascertained. 

Female;  age  20;  born  in  U.  S. ;  typist;  unmarried 
mother  with  one  child;  seduced  at  18  years  by  an 
Italian.  Following  death  of  father,  sent  to  orphan 
asylum  at  age  of  ten  years. 

Showed  kleptomaniac  tendencies  at  orphan  asylvmi ; 
after  discharge  at  age  of  fifteen  consorted  with  gang 
of  thieves,  acting  as  female  accomplice.  Finally  ar- 
rested, sent  to  City  Prison  to  await  trial ;  actions  and 
behavior  caused  transfer  to  psychopathic  ward  for 
observation  and  examination ;  found  that  she  was  not 
a  committable  case  though  subject  to  mild  disturb- 
ances of  short  duration.  Paroled  by  court  and  re- 
ferred to  mental  hygiene  agency. 

Meihod 

Mental.  Examined  at  clinic  regularly  and  advised. 

Physical.  Needs  attended  to. 

Social.  Given   clerical    work ;   board   paid    as  long  as   was 

necessary ;  clothing  provided  ;  baby  boarded  with  its 
father's  relatives;  worker  saw  patient  regularly  for 
two  years  and  at  intervals  for  several  years  thereafter ; 
obtained  a  stenographic  position. 

Recreational.      Advised  very  carefully. 

Restdt 
Patient  has  had  a  regular  position  for  several  years 
as  stenographer  in  the  government  service,  salary 
$1200  per  year;  pays  board  for  child,  of  which  she 
is  very  fond.  Consistently  refuses  to  marry  father  of 
the  child  ;  has  had  no  difficulties  for  several  years ; 
thoroughly  adjusted. 


The  presentation  of  these  twenty-five  cases,  even  though 


369]  SOCIAL  TREATMENT  OF  INSANE  22y 

in  outline  form  only,  should  give  to  the  reader  a  compara- 
tively fair  conception  of  the  problems  that  are  faced  by 
physicians  and  social  workers  in  the  clinics  of  an  organiza- 
tion specializing  in  the  social  service  side  of  mental  hygiene 
activities.  The  various  combinations  of  circumstances, 
though  numerous  as  far  as  these  few  cases  are  concerned,  do 
not  exhaust  the  wide  range  of  possible  problems  that  arise 
in  dealing  with  mental  hygiene  patients.  The  attempt  has 
been  not  to  present  selected  and  chosen  cases,  but  rather  to 
indicate  as  far  as  possible  what  amounts  to  a  cross-section  of 
the  work  in  its  various  phases.  Lack  of  space  alone  pro- 
hibits the  presentation  of  one  hundred  or  more  cases,  in  each 
of  which  a  particular  set  of  problems  need  solution.  Every 
mental  patient  and  his  family  are  the  source  of  a  new  group 
of  difficulties ;  and  although  certain  of  these  can  be  pigeon- 
holed as  it  were,  still  each  patient  must  be  studied  separately, 
a  plan  for  serving  prepared  and  without  hesitation  modified 
as  the  exigencies  of  the  developing  situations  demand. 


' "  CHAPTER  VI 

Recommendations  and  Conclusion 

i.  shortcomings  of  social  service 

The  activities  of  most  social  service  agencies  depend  for 
their  efficacy  and  sphere  of  influence  for  good  in  a  com- 
munity upon  the  funds  available  from  year  to  year,  upon  the 
personnel,  the  equipment  with  which  they  have  to  work, 
and  the  moral  support  of  the  socially  minded  persons  whose 
interest  is  aroused  in  their  work.  This  is  as  true  of  a 
mental  hygiene  as  of  any  other  agency.  In  a  large  com- 
munity like  New  York  City,  there  is  never  a  dearth  of 
patients ;  the  problem  is  rather  to  obtain  sufficient  funds  to 
maintain  clinics  in  different  parts  of  the  greater  city  and  to 
render  both  medical  and  social  service  of  a  high  order. 

From  the  cases  cited  in  the  preceding  chapter  it  was  seen 
that,  at  least  with  some  types  of  patients,  such  as  those 
afflicted  with  manic  depressive  insanity,  much  can  be  ac- 
complished and  the  patients  saved  from  commitment  to  a 
state  hospital  for  the  insane.  Social  service  has  been  less 
successful  with  cases  of  dementia  praecox,  general  paralysis, 
paranoid  conditions,  psychoneuroses  and  others.  This  lack 
of  success  corresponds  to  the  failure  of  the  state  hospitals 
to  improve  the  mental  condition  of  patients  similarly  diag- 
nosed. From  one  point  of  view,  however,  this  comparison 
is  not  altogether  justified.  Social  service  with  mental  cases 
aims  to  achieve  just  what  state  hospitals  have  thus  far 
failed  to  accomplish ;  if,  therefore,  psychiatric  social  work 
is  to  develop  upon  a  firm  basis  it  must  prove  its  utility  as  an 
important  and  distinct  factor  in  increasing  the  ratio  of  re- 
228  [370 


371  ]  RECOMMENDATIONS  AND  CONCLUSION  229 

coveries  and  eventually  decreasing  the  incidence  of  insanity 
and  psychoneuroses. 

II.    NEED  OF  A  NEWER  METHOD  OF  APPROACH  TO  PROBLEM 

While  it  is  true  that  social  service,  as  at  present  organized, 
functions  most  satisfactorily  with  cases  of  manic  depressive 
insanity,  it  must  be  recognized  that  psychiatric  social  work 
has  been  largely  limited  to  treating  and  caring  for  acute, 
chronic  and  occasionally  borderline  cases,  and  that  the  much 
broader  field  of  prevention  has  in  the  main  been  neglected. 
Why  this  should  be  so'  is  quite  understandable.  The  atten- 
tion of  the  public,  of  the  legislatures,  and  of  physicians  has 
been  absorbed  in  providing  suitable  places  of  confinement 
for  those  who  have  already  shown  symptoms  of  mental 
disease;  and,  as  has  been  repeatedly  pointed  out,  even  thig 
phase  of  the  problem  is  still  far  from  being  adequately  met. 

During  the  past  few  years,  particularly  since  the  develop- 
ment of  the  mental  hygiene  movement,  it  has  become  more 
and  more  apparent  that  one  of  the  chief  reasons  for  the  low 
percentage  of  recovery  and  improvement  has  been  the  cir- 
cumstance that  those  ailing  mentally  are  not  reached  soon 
enough  either  by  mental  hygiene  clinics  or  by  the  state  hos- 
pitals. Only  in  cases  of  acute  attacks  are  the  patients  given 
early  care  and  treatment ;  where  the  onset  of  the  disease  is 
gradual  and  spread  over  weeks  or  months,  the  patient  too 
often  comes  to  the  attention  of  the  specialist  in  mental 
diseases  when  nothing  but  state  hospital  care  can  be  recom- 
mended. 

The  implications  of  these  facts  are  obvious,  and  if  we 
are  to  achieve  greater  success  in  helping  those  who  are 
headed  towards  the  state  hospital  for  the  insane,  we  must 
begin  to  attack  the  problem  in  a  different  way.  Maintain- 
ing clinics  for  the  mentally  sick,  psychiatric  social  work, 
state  hospitals  for  the  insane,  psychopathic  hospitals,  and 


230     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [372 

other  agencies  that  are  called  upon  to  help  meet  the  problems 
that  arise,  are  one  and  all  essential  in  a  program  aiming  to 
conserve  the  mental  health  of  a  community.  But  the  goal 
to  be  sought  by  all  who  are  interested  in  the  problem  of 
insanity  should  be  a  gradual  decrease  in  the  number  of 
persons  whom  it  is  found  necessary  to  commit  to  state 
hospitals  and  similar  institutions.  Instead  of  striving  to 
obtain  larger  and  still  larger  appropriations  for  additional 
state  hospital  accommodations,  as  is  im fortunately  being 
done  at  the  present  time,  ordinary  prudence  would  indicate 
that  some  other  or  additional  action  was  necessary  to  limit 
the  ever  increasing  need  to  maintain  in  comparative  indol- 
ence thousands  of  persons  who  have  or  will  become  mentally 
ill. 

III.    MENTAL  HYGIENE  AND  CHILDHOOD 

From  the  point  of  view  of  mental  hygiene,  individuals 
may  be  said  to  fall  into  one  of  the  following  groups :  (a) 
those  now  sane,  and  who  will  remain  sane  except  through 
the  working  of  some  exogenous  factor;  (b)  those  now 
sane,  but  who  will  become  insane  under  certain  conditions ; 
(c)  those  now  insane;  (d)  those  who  have  been  insane 
but  who  are  now  recovered  and  have  returned  to  the  com- 
munity. To  this  might  be  added  a  fifth  group — those  yet 
unborn.^  From  this  it  is  seen  that  those  who  belong  to  the 
first  two  groups,  whether  children  or  adults,  may.  under 
certain  unfavorable  conditions,  come  in  time  to  be  a  part 
of  groups  (c)  and  (d).  Our  chief  problem  is  how  to  pre- 
vent this  from  coming  about,  particularly  insofar  as  the 
children  are  concerned. 

Students  of  psychiatry  have  come  to  realize  more  and 
more  that  the  patients  whom  they  liave  observed  in  hos- 

1  Williams,  Frankwood  E.,  "  Psychopathic  Hospitals  and  Prophylaxis," 
Boston  Med.  and  Surg.  Jour.,  June  24,  191 5,  p.  933. 


373]  RECOMMENDATIONS  AND  CONCLUSION  231 

pitals  for  the  insane  and  elsewhere  were  in  need  of  special 
study  and  care  as  children,  and  that  it  was  the  duty  of 
society  to  have  discovered  their  special  needs  and  to  have 
given  them  the  attention  which  their  future  welfare  de- 
manded/ Viewing  the  matter  from  the  basis  of  our  pre- 
sent knowledge,  we  may  be  inclined  to-  forgive  the  failings 
of  a  generation  ago,  though  an  enlightened  public  opinion 
is  to-day  demanding  that  preventive  measures  be  taken 
early  enough  in  the  lives  of  children  to  discover  and  when 
possible  to  correct,  faulty  habits  of  mind  and  action  which 
in  later  life  may  result  in  the  development  of  some  neurosis  - 
or  psychosis.  A  program  which  would  show  definite  re- 
sults would  of  necessity  have  to  concern  itself  with  children 
of  a  very  early  age.  A  plan  prepared  by  Prof.  Arnold 
Gesell  of  Yale  University  for  the  complete  examination  of 
children  includes  the  following  measures,  which  would  be 
particularly  applicable  to  a  large  city,  though  likewise  ad- 
justable to  rural  and  village  conditions :  " 

(a)  A  hygienic  supervision  of  the  pre-school  period. 
This  to  result  in  a  cumulative  biographic  record  of  every 
child  from  birth  registration  to  school  entrance. 

(b)  A  psycho-physical  entrance  examination  of  every 
school  beginner.  This  examination  should  be  compre- 
hensive, thoroughgoing  and  in  close  cooperation  with 
parent  or  guardian ;  it  should  also  summarize  the  main  con- 
clusions from  the  pre-school  career  of  the  child  and  disclose 
those  children  either  superior  or  atypical  who  most  urgently 
need  a  specialized  school  career. 

(c)  A  reorganization  of  the  kindergarten  and  first  year, 
which  will  place  the  first  half  year  of  school  life  under 
systematic,  purposeful  observation. 

^  Yerkes,  Robert  M.,  "  How  We  May  Discover  Children  Who  Need 
Special  Care."  Mental  Hygiene,  April,  1917,  p.  252. 

*  Gesell,  Arnold,  "Mental  Hygiene  and  the  Public  School,"  Mental 
Hygiene,  Jan.,  19 19,  pp.  4-10. 


232     SOCIAL  ASPECTS  Of  TREATMENT  OF  INSANE     [374 

(d)  The  development  of  a  new  type  of  school  nurse, 
who  by  supervision,  corrective  teaching,  and  home  visit- 
ing, will  further  the  concrete  everyday  tasks  of  mental 
hygiene.  Her  problems  would  be  children  with  night  ter- 
rors, the  nail  biter,  the  over  tearful  child,  the  over  silent  child, 
the  stammering  child,  the  extremely  indififerent  child,  the 
pervert,  the  infantile  child,  the  unstable  choreic,  and  a  whole 
host  of  suffering,  frustrated  and  unhealthily  constituted 
growing  minds,  that  we  are  barely  aware  of  in  a  quantita- 
tive sense,  because  we  do  not  have  the  agencies  to  bring  them 
to  our  attention  as  problems  of  public  hygiene  and  pro- 
phylaxis. 

(e)  The  development  of  reconstruction  schools,  of 
special  classes  and  vacaltion  camps  for  certain  groups  of 
children  who  need  specialized  treatment,  such  as  the  speech 
defective,  psychopathic  and  nervous  groups.  To  such 
schools,  classes  and  camps,  children  could  be  assigned  for 
long  or  short  periods,  and  secure  a  combination  of  medical 
and  educational  treatment  which  alone  is  adequate  to  re- 
construct them  mentally.  These  provisions  imply  neuro- 
logical and  psychiatric  specialists,  educational  psychologists 
and  teacher-nurses,  cooperating  as  public  health  experts 
in  a  work  of  mental  salvage  and  prophylaxis. 

Only  by  such  radical  and  sincere  methods  can  we  ever 
hope  to  reduce  the  massive  burden  of  adult  insanity.  Ex- 
pensive in  the  beginning,  a  preventive  juvenile  system  of 
mental  sanitation  may  after  all  prove  to  be  a  form  of 
socialized  thrift. 

IV.    MENTAL   HYGIENE   AND  ADOLESCENCE 

Adolescence  is  generally  recognized  as  a  critical  period 
in  the  mental  life  of  the  individual.  Not  only  is  it  a  period 
during  which  disorders  are  very  apt  to  develop,  but  it  is  also 
a  time  when  the  mental  balance  of  probably  every  boy  and 


375]  RECOMMENDATIONS  AND  CONCLUSION  233 

girl  is  disturbed  to  a  greater  or  lesser  degree.  In  fact,  many 
of  the  breaks,  perhaps  most  of  them,  occur  in  the  adolescent 
period  or  the  period  of  early  adulthood/  The  disturbance 
is  shown  in  a  variety  of  ways,  as  for  example,  by  a  tendency 
to  become  irritable  and  discontented  or  to  indulge  in  day- 
dreams and  romantic  fancies.  The  changes  in  behavior  and 
disposition  which  young  people  display  ait  that  time  fre- 
quently make  them  difficult  to  deal  with  and  cause  a  great 
deal  of  trouble  and  worry  to  those  whoi  are  responsible  for 
their  care  and  upbringing. 

Emphasis  has  already  been  placed  upon  the  need  for  the 
early  recognition  of  latent  or  active  mental  disorders;  and 
upon  the  fact  that  approximately  sixty  per  cent  of  the 
patients  in  the  state  hospitals  in  New  York  State  have  been 
diagnosed  as  cases  of  dementia  praecox,  with  a  history, 
following  the  age  of  puberty,  of  inability  for  healthy  mental 
adjustment.  In  these  patients,  the  inability  to  adjust  them- 
selves resulted  in  unwholesome  habits  of  thought  and  con- 
duct, in  bad  sexual  practices  or  antisocial  acts,  and  in  certain 
types  of  mental  reactions  usually  regarded  as  manifestations 
of  mental  disease. 

In  preventing  the  development  of  these  unhealthy  types  of 
mental  adjustment  during  the  adolescent  period,  there  is  a 
very  important  field  of  work  and  one  in  which  very  little 
has  as  yet  been  done.  There  are  few  boys  or  girls  who 
would  not  be  the  better  for  some  assistance  and  guidance 
during  the  adolescent  period.  There  are  many  with  whom 
it  would  make  all  the  difiference  between  becoming  useful 
members  of  society  and  permanent  inmates  of  institutions. 
The  time  to  deal  with  these  disorders  and  difficulties  of  ad- 
justment is  just  as  soon  as  they  appear,  though  the  pre- 

1  White,    William    A.,    "Childhood:    the   Golden    Period    for    Mental 
Hygiene,"  Mental  Hygiene,  Apr.,  1920,  p.  266. 


234     SOCIAL  ASPECTS  OP  TREATMENT  OP  INSANE     [376 

liminary  training  should  be  initiated  long  before  in  order 
to  inhibit  their  later  development.  The  adolescent  boy  or 
girl  should  be  helped  to  make  a  wholesome  adjustment  to 
the  demands  of  his  instinctive  nature  in  the  first  place,  for 
by  the  time  he  reaches  a  hospital  for  the  insane,  he  has 
commonly  departed  so  far  from  normal  habits  of  thought 
and  conduct  that  attempts  to  reeducate  him  are  of  very  little 
use.^  There  must  be  psychiatrists  in  the  upper  grades  of 
the  public  schools  and  in  the  high  schools,  for  frequently  it 
is  there  that  incipient  mental  disorder  first  shows  itself. 
There  must  be  more  mental  hygiene  clinics  and  education 
of  the  public  in  regard  to  the  subject  of  mental  hygiene. 

It  may  be  interesting  to  note  at  this  point  that  the  mental 
hygiene  division  of  the  Free  Synagogue,  of  which  mention 
has  already  been  made,  has  established  and  maintains  a 
^country  home  or  camp  to  which  are  sent  adolescent  girls  re- 
commended by  physicians,  nurses,  teachers,  social  service 
agencies  and  others.  The  girls  are  examined  by  a  psychia- 
trist and  if  found  to  be  cases  of  mental  maladjustment  in 
danger  of  developing  some  mental  or  nervous  disorder,  they 
are  sent  to  the  camp  for  a  period  of  several  weeks  or  even 
months.  While  there  they  are  under  the  constant  and 
direct  supervision  of  a  nurse  specially  trained  in  work  with 
this  type  of  girl.  They  are  followed-up  after  discharge, 
hold  reunions  throughout  the  fall  and  winter,  and  in  case  of 
further  need  of  country  care  are  permitted  to  return  to  the 
camp  until  their  condition  has  shown  marked  improvement. 
The  experiment  has  well  justified  the  expense  involved  and 
raises  the  hope  that  similar  camps  or  convalescent  homes 
for  other  groups  will  prove  to  be  a  ver)-  effective  means  of 
preventing  mental  and  nervous  breakdowns  in  later  life. 

1  Harrington,  Milton  A.,  "  Mental  Disorder  in  Adolescence,"  Mental 
Hygiene,  Apr.,  1920,  p.  379. 


^yy-^  RECOMMENDATIONS  AND  CONCLUSION  235 

V.    MENTAL  HYGIENE  NEEDS  OF  A  COMMUNITY 

The  object  of  this  study  having  been  largely  limited  to 
a  consideration  of  the  social  aspects  of  the  treatment  of  the 
insane,  it  may  be  worth  while  to  point  out  in  closing,  the 
fundamental  items  of  a  mental  hygiene  program  for  a  com- 
munity, taking  for  granted  that  the  thoughts  already  ex- 
pressed, particularly  upon  the  problem  of  the  child  and  the 
adolescent,  do  not  need  reiteration. 

Mental  hygiene  activities,  as  will  be  remembered,  aimed 
first  of  all  to  educate  the  mass  of  people  regarding  the  essen- 
tials of  proper  nervous  and  mental  life.  Following  this 
came  the  establishment  of  mental  hygiene  clinics  with  their 
psychiatrists  and  specially  trained  social  workers.  The 
plan  of  activities  of  certain  mental  hygiene  clinics  operating 
in  New  York  City  was  presented  in  the  preceding  chapter 
and  it  was  implied  that  the  equipment  of  the  mental  hygiene 
agency  operating  these  clinics  is  by  no  means  adequate  to 
meet  the  pressing  needs.  It  is  not  merely  a  question  of 
inadequate  financial  resources  to  establish  more  clinics  in 
different  parts  of  the  city;  other  fundamentals  are  lacking  to 
round  out  the  activities  and  power  for  service  to  the  com- 
munity. A  presentation  of  these  will  go  a  considerable 
way  toward  indicating  what  the  minimum  facilities  should 
be  in  every  large  community  in  order  to  meet  the  mental 
hygiene  requirements. 

First  of  all  we  can  proceed  on  the  assumption  that  in  any 
given  community  the  mental  hygiene  facilities  are  not  ade- 
quate to  serve  those  in  pressing  need  of  this  kind  of  medical 
attention.  /There  is  not  a  city  of  any  size  where  sufficient 
emphasis  is  being  placed  upon  the  mental  health  of  the 
populationwcither  through  the  activities  of  the  public  institu- 
tions and  their  officers,  bv  private  agencies,  or  a  combina- 
tion of  both.  The  fact  of  the  matter  is  that  the  mental 
hygiene  idea  is  only  beginning  to  take  root  in  various  sec- 


236     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [378 

tions  of  the  country.  It  will  be  some  time  before  an 
awakened  and  aroused  public  conscience  takes  recognition 
of  its  needs,  spurred,  perhaps,  by  the  propaganda  and  stimu- 
lation of  local  societies  for  mental  hygiene  or  by  the 
National  Committee  for  Mental  Hygiene. 

It  should  again  be  made  plain  that,  as  at  present  organ- 
ized, state  hospitals  are  not  prepared  to  meet  the  mental 
hygiene  needs  of  a  community  without  the  active  assistance 
and  financial  support  of  private  organizations.  By  this  is 
meant  that  the  private  agencies  should  cooperate  with  and 
supplement  the  work  of  the  state  hospitals  by  various  activi- 
ties, some  of  which  will  be  explained  in  the  following  section. 

VI.    MENTAL    HYGIENE   AGENCIES 

At  least  four  elements  are  necessary  to  the  proper  organi- 
zation of  a  mental  hygiene  agency.  These  are  (a)  clinics; 
(b)  convalescent  homes;  (c)  a  model  factory  or  workshop; 
and  (d)  a  psychiatric  institute  functioning  in  conjunction 
with  the  other  items  in  the  program. 

(a)  Clinics.  Clinic  organization  and  plan  of  service  have 
already  been  discussed  and  will  be  passed  over  at  this  point, 
except  to  note  the  further  suggestion  that  before  the  estab- 
lishment of  any  clinics  in  a  community  a  survey  should  be 
made  of  the  distribution  of  the  population  that  is  most  likely 
to  come  to  these  mental  hygiene  clinics.  Moreover,  when- 
ever possible,  such  clinics  should  be  established  within  the 
buildings  of  a  general  hospital.  With  the  development  of 
hospitals  as  health  centers,  it  seems  most  advisable  that 
mental  hygiene  clinics  should  also  become  part  of  the  com- 
munity health  program. 

(b)  Convalescent  Homes.  Those  engaged  in  psychia- 
tric social  work  often  feel  themselves  at  a  loss  as  to 
where  to  send  a  mental  case  in  need  of  convalescent  care. 
It  may  l:>e  of  interest  to  note  that  there  is  hardly  a  con- 


379]  RECOMMENDATIONS  AND  CONCLUSION  237 

valescent  home  or  institution  in  or  near  New  York  City  at 
present  that  will  accept  as  an  inmate  one  who  has  been  dis- 
charged from  a  state  hospital  and  is  in  need  of  a  temporary 
change  of  environment  or  convalescent  care.  The  only  in- 
stitution approximating  such  a  place  which  receives  mental 
cases  is  the  camp  already  mentioned,  and  to  which,  because 
of  lack  of  room,  only  adolescent  girls  are  admitted.  As  a 
result  of  this  state  of  affairs,  early  mental  cases  and  those 
verging  upon  a  breakdown  must  be  committed  to  state  hos- 
pitals from  which  they  might  otherwise  be  saved,  or  they 
must  be  sent  to  private  sanatoria,  where  the  standard  of 
care  and  attention  is  often  inferior.  In  the  case  of  single 
persons  without  any  immediate  relatives  or  friends  in  the 
community,  the  attempt  has  to  be  made  at  an  early  stage  to 
board  them  in  selected  private  homes.  None  of  these  ex- 
pedients has  as  yet  been  found  satisfactory.  The  only 
solution  that  seems  at  all  feasible  is  the  establishment  of  one 
or  more  convalescent  homes  specializing  in  the  care  of 
mental  cases.  These  might  be  similar  to  the  institutions 
already  in  existence  to  which  are  sent  persons  in  danger  of 
a  physical  breakdown,  or  those  recuperating  from  surgical 
operations  and  severe  physical  ailments. 

(c)  Workshop  for  Mental  Hygiene  Patients.  From  a 
reading  of  the  cases  cited  in  the  preceding  chapter  it  must 
have  been  realized  that  one  of  the  main  difficulties  faced  in 
trying  to  assist  patients  to  readjust  themselves  was  the 
inability  to  provide  suitable  employment  for  them  under 
favorable  working  conditions.  It  is  not  very  difficult  to 
find  some  kind  of  work  when  there  is  a  labor  shortage,  but 
the  problem  is  so  to  place  mental  hygiene  patients  that  for 
one  reason  or  another  they  will  not  feel  compelled  to  leave 
the  job  found  for  them  within  a  few  hours  or  days  after 
beginning  work.  The  difficulty  is  that  these  persons  cannot 
fit  into  what  we  to-day  call,  whether  rightly  or  wrongly,  the 


238     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [380 

normal  industrial  life.  They  must  liave  working  condi- 
tions specially  planned  to  meet  their  particular  needs. 
Thus,  tlie  recovered  and  improved  cases  of  manic  depressive 
insanity  find  it  well-nigh  impossible  to  return  to  former 
sweatshop  and  high-speed  industrial  life  without  exposing 
themselves  to  a  relapse  and  readmission  to  the  state  hospital. 
The  numerous  early  cases  of  dementia  praecox  and  others 
lose  one  position  after  another  because  the  employer  does 
not  understand  and  refuses  to  sympathize  with  their  con- 
dition and  discharges  them  when  they  repeatedly  come  late 
in  the  morning,  when  they  feel  indisposed  and  remain  away 
from  work,  and  otherwise  fail  to  measure  up  to  the  standard 
and  pace  set  by  their  healthy  fellow-workers. 

Suitable  occupation  under  favorable  conditions  is  an 
established  and  recognized  therapeutic  agent  for  mental 
cases.  To  prevent  the  numerous  relapses  and  hospital  read- 
missions,  as  well  as  to  stave  off,  in  the  first  place,  the  need 
for  commitment  because  of  social  maladjustment  arising 
from  industrial  and  occupational  difficulties,  model  work- 
shops for  mental  hygiene  patients  should  be  established. 
A  workshop  for  Jewish  men  and  women  afflicted  with 
tuberculosis  has  for  several  years  1>een  in  operation  in  New 
York  City  under  the  direction  of  a  social  agency.  The 
project  long  ago  outgrew  the  experimental  stage  and  has 
from  its  inception  been  a  successful  venture  from  the 
social,  medical,  occupational  and  economic  viewpoints.  The 
same  kind  of  workshop,  with  certain  necessary  modifications, 
should  be  established  for  mental  hygiene  patients.  It  would 
then  not  be  necessarj^  for  patients  discharged  from  state 
hospitals  to  reenter  at  once  the  industry  which  in  the  first 
place  contributed  to  their  mental  or  nervous  breakdown. 
Those  suffering  from  the  milder  forms  of  mental  disease 
could  find  gainful  occupation  where  they  would  work  under 
the  supervision  of  those  who  understood  their  condition, 


381]  RECOMMENDATIONS  AND  CONCLUSION  239 

and  where  they  would  not  be  compelled  to  work  when  they 
were  not  well.  The  establishment  of  such  an  industrial 
unit  or  center  would  indeed  be  a  landmark  in  the  develop- 
ment of  the  health  conscience  of  the  community,  and  in  the 
progress  of  the  mental  hygiene  movement. 

(d)  Psychopathic  Hospital.  The  fourth  element  neces- 
sary to  round  out  the  program  of  work  of  a  mental  hygiene 
organization  is  a  psychopathic  hospital,  to  which  might  be 
admitted  for  observation  and  treatment  cases  of  mild  men- 
tal disturbance  otherwise  destined  to  go  about  neglected 
until  they  finally  had  to  be  sent  to  a  state  hospital.  The 
need  for  such  an  institution  is  particularly  apparent  in  a 
large  cosmopolitan  city  like  New  York,  with  its  thousands 
of  admissions  annually  to  the  psychopathic  wards  of  general 
hospitals,  from  which  but  comparatively  few  are  discharged 
except  to  a  state  hospital.  Such  an  institution  as  proposed 
would  be  in  a  position  to  treat  patients  long  before  they 
were  in  need  of  state  hospital  care,  and  only  such  patients 
as  it  was  possible  to  help  to  mental  health  within  a  compara- 
tively short  time  would  be  admitted  for  treatment. 

The  question  of  the  utility  of  psychopathic  or  reception 
hospitals  has  been  discussed  elsewhere  and  will  not  be 
reopened.  It  is  sufficient  to  state  that  in  large  communities 
such  an  institution  is  essential  to  a  complete  plan  for  the 
early  care  and  treatment  of  mental  and  nervous  cases,  and 
that  the  work  and  results  of  the  Boston  Psychopathic  Hos- 
pital as  well  as  of  the  Phipps  Institute  in  Baltimore  have 
completely  justified  the  hopes  of  the  original  sponsors  of 
the  idea. 

It  is  felt  by  many  students  of  the  problem  in  New  York 
City,  that,  due  to  the  large  Jewish  population  in  New  York, 
as  well  as  to  the  peculiar  psychology  of  the  Jew  and  more 
especially  of  the  recent  immigrants  among  the  Jews,  it  would 
be  advisable  to  plan  and  erect  a  Jewish  psychopathic  hos- 


240     SOCIAL  ASPECTS  OF  TREATMENT  OF  INSANE     [382 

pital  or  institute,  either  as  an  independent  unit  or  as  a  part 
of  an  already  established  general  or  special  hospital.  The 
organization  of  a  committee  representative  of  various 
elements  of  the  community  and  interested  primarily  in  pre- 
ventive and  reconstructive  work  along  lines  of  mental 
hygiene,  and  the  establishment  of  clinics,  convalescent  homes, 
workshops,  and  a  psychopathic  hospital,  would  be  a  great 
step  forward  in  mental  hygiene  and  psychiatric  social  work. 
Such  a  group  has  already  been  formed  among  the  Jews 
of  New  York,  but  its  efforts  are  still  in  their  infancy.  The 
plan  outHned  for  a  community  program  is  applicable  to 
any  city,  though  it  would  have  to  be  modified  somewhat  to 
meet  local  conditions. 

VII.    CONCLUSION 

In  attempting  to  point  out  and  discuss  the  social  aspects 
of  the  treatment  of  the  insane,  the  primary  aim  of  the 
writer  has  been  to  bring  before  those  who  are  vitally  in- 
terested in  the  whole  and  baffling  question  of  insanity, 
whether  from  the  viewpoint  of  the  physician,  minister, 
social  worker  or  layman,  facts  which  will  lead  to  a  better 
understanding  of  the  various  phases  of  the  problem.  The 
presentation  of  the  development  of  legislation  affecting  the 
insane  in  New  York  State  in  the  first  chapter  was  intended 
as  a  background  upon  which  to  picture  the  other  aspects 
which  were  later  considered,  for  much  of  the  care  and 
treatment  of  the  insane  is  integrally  related  tO'  the  question 
of  legislation.  The  three  subsequent  chapters  presented, 
first,  the  patient  before  coming  to  and  while  in  the 
psychopathic  ward  of  a  general  hospital  as  well  as  the 
disposition  of  such  patients ;  second,  the  patient  in  the  state 
hospital  to  which  he  was  transferred  from'  the  psychopathic 
ward,  and  his  disposition  by  the  state  hospital ;  and  third,  the 
patient  after  leaving  the  state  hospital.     These  three  chap- 


383]  RECOMMENDATIONS  AND  CONCLUSION  241 

ters  indicated  what  the  city  and  state  were  doing  for  the 
insane  who  came  under  their  care.  The  fifth  chapter  por- 
trayed the  activities  of  a  privately  supported  social  agency 
specializing  in  mental  hygiene  activities.  The  recommenda- 
tions of  the  final  chapter  point  out  the  lines  the  newer  work 
for  mental  cases  will  have  to  follow  in  order  to  achieve  a 
higher  degree  of  success  in  preventing  and  curing  insanity. 
With  the  public  aroused  to  a  deeper  interest  in  all  that  per- 
tains to  the  insane,  improved  methods  of  treating  mental 
disorders  would  develop  apace. 


INDEX 


Accommodations,  154 

Acute  cases,  38,  41,  83,  229 

Adjustment,  152,  161,  163,  234 

Admissions,  Table  of,  71 

Admissions,  total,  155 

Adolescence,  85,  2^2,  233,  234 

Advice,  176,  178 

After-care,  Z7,  38,  138,  I49,  i75 

After-care  worker,  139,  140,  177 

Age,  121 

Age  distribution,  97,  98 

Agency,  child-caring,  164 

Agency,  social,  157,  194 

Alcohol,  66 

Alcoholic  insanity,  66,  67,  68 

Alcoholic  patients,  99 

Alcoholism.  80,  90,  105 

Aliens,  deported,  100 

America,  113 

Almshouses,  insane  in,  19,  24.  60 

American  Red  Cross,  159 

Amityville  Sanatorium,  103 

Anglo-Saxons,  insanity  among,  50 

Ann  Arbor,  40 

Anorexia,  85 

Appropriations,  115 

Arabia,  98 

Arabs,  insanity  among,  49 

Army,  159 

Arteriosclerosis,   68,    72,    98,    105, 

142, 
Assistance,  financial,  56,  64 
Asylum,  insane,  119 
Asylum,  orphan,  59,  64,  66 
Asylum,  private,  30 
Asylums,  state,  19 
Attendants,  113,  119,  126,  130,  131, 

154 
Auburn,  2^ 
Austria-Hungary,  98 
Autointoxication,  87 

Bailey,  Dr.  Pearce,  107 
Baltimore,  40,  132,  239 
Bandages,  restraining,  147 
385  J 


Bath,  continuous,  147 

Beadles,  C.  F.  49 

Bedouins,  insanity  among,  49 

Beers,  Clifford  W.,  189 

Belgium,  98 

Belle  Meade  Sanatorium,  103 

Bellevue  Hospital,  Psychopathic 
Wards,  23,  38,  39,  48,  50,  52,  55, 
70,  93.  108,  115,  116,  117,  120,  126, 

127,  135,   149,  150,  162,  168,  180, 
185,  191 

Binghamton  Asylum,  28 
Blackwell's  Island,  23,  105 
Bloomingdale  Hospital,  18,  20,  122 
Board  of  Charities,  State,  26 
Borderline  cases,  83,  130,  189,  194 
Borderline  condition,  195 
Borderline    patients,    commitment 

of,  58 
Boston,  40,  132,  191 
Boston      Psychopathic     Hospital, 

139,  ^29 
Brain  tumor,  79 
Breakdown,  mental,  132 
Breakdown,  physical,  237 
British  Commission  in  Lunacy,  33 
Bronx  Borough,  52 
Brooklyn,  40 

Brooklyn  State  Hospital,  126 
Buffalo  State  Hospital,  26 

Cabot,  Dr.  Richard  C,  189,  191 

California,  118 

Camps,  vacation,  232,  234 

Cancer,  105 

Celtic  race,  insanity  among,  50 

Central  Islip   State  Hospital,   127, 

128,  129,  135,  136,   137,  139,  143, 
150,  170,  178 

Chain  period,  147 

Charitable  organizations,  repre- 
sentative of,  58 

Charities  Aid  Association,  State, 
31,  2,7,  45 

Child-placing  institutions,   194 
243 


244 


INDEX 


[386 


Child  Welfare,  Board  of,  164 

Childhood,  230 

Children,  Dependent,  95,  167,  185 

Children,  minor,  158,  159,  163,  166 

Children,  nervous.  232 

Children,  placing-out  of,  166 

Children,  psychopathic,  232 

Chorea,  78,  79,  81 

Chorea,  Huntington's,  79 

Chronic  cases,  229 

Citizens,  future,  157 

City  Hospital,  105 

City  Prison,   106 

Classes,  arts  and  crafts,  122 

Classification  of  patients,  120,  130, 

131,  ^33,  136,  156 
Classification,  uniformity  of,   121 
iClimateric,  69 
Clinics,    mental    hygiene.    38,    170. 

172,  175,  189,  194,  227,  234,  235, 

236 
Clinic  physician,  182 
Clinic  staff,  194 
Clinics,  state  hospital,  179 
Colonial  legislation,  16 
Colony,  industrial,  91 
Combes,  Dr.,  Sanatorium,  103 
Commission  in  Lunacy,  State,  32, 

Commissioner  in  Lunacy,  State, 
26,  27,  28,  31,  32,  38 

Commitment  papers,  103 

Commitment  of  patients,  24,  54, 
SS,  56,  57,  IIS,  118.  125.  137,  174 
194 

Commitment  Law,  59 

Confusion,  transitory,  92 

Consolidated  Laws,  54 

Constitutional  psychopathic  infer- 
iority, 92,  loi,  105,  107,  145,  223^ 
224,  226 

Convalescent  care,  194,  237 

Convalescent  homes,  194  234,  236 

Convalescents,   194 

Cottages.  121 

County  asylums.  29,  30 

County  authorities.  21 

Court,  children's.   107 

Court,  magistrate's,  106 

Craig.  Maurice,  61 

Creedmoor,  115 

Criminals,  insane,  22 

Crowded  conditions,  116 

Cumberland  St.  Hospital.  108 


Daydreams,  233 

Death,  cause  of,  no 

Death  rate,  140,  143,  151 

Death  rates,  increasing,  141 

Deaths,  140,  146,  155 

Deaths  in  institutions,  141 

Deaths  in  psychopathic  wards,  109 

Delinquent,  105 

Dementia  praecox,  78,  99,  122,  129, 
130,  145,  181,  183,  205,  206,  208, 
228,  233,  238 

Dementia  praecox,  age  distribu- 
tion of,  88 

Dementia  praecox,  allied,  213 

Dementia  praecox,  commitment 
of,  88 

Dementia    praecox,    hebephrenic 

94 
Dementia  praecox,  katatonic,  144, 

210 
Dementia  praecox,  paranoid,  211 
Demoniacal  exorcism,  15 
Deportation,  99,  100,  102,  164 
Deportation,  Bureau  of,  37,  100 
Depression,  episodes  of,  92 
Depression,  undifferentiated,  93 
Dercurn,  Francis  X.,  61 
Desertion,  167 
Detention  period,  118,  120 
Devine,  Dr.  Edward  T.,  150 
Diagnosis,  methods  of,  133 
Dietary  laws,  131,  192 
Disease,  venereal.  162,  16S 
Diseases,  infectious,   87 
Dispensary,  182 
District  of  Columbia,  ir8 
Divorce.   168 
Dix,  Dorothea  L.,  25 
Domestics,  125 
Drug  addicts,  105 
Dubois,  Dr.  Paul,  160 
Dungeon  period,  147 

Educational  Campaign,  193 
Efficiency  and  Economy,  Dept.  of, 

122 
Employment.    123,    137,    176,    182, 

184 
Employment  agencies,   195 
Empyema.  8r 
England,  98,  172 
EngHsh   language,    192 
Environment,  92,  100,  112.  118,  139, 

194 
Epilepsy,  90,   IDS,  145 


3S7] 


INDEX 


245 


Erie  County,  29 
Europe,  157.  I59,  i^4 
Europe,  legislation  in,  34 
Examination,  mental,  117,  188 
Excitement,  episodes  of,  92 

Factory,  Model,  236 
Feebleminded,  44 
Field  agent,  169,  171 
Fishkill-on-the-Hudson,    23 
Flatbush,  22,  24 
Follow-up,  137,  138,  178,  190 
Foreign-born,   70,  96,  97,  98,    125. 

130,  131 
Foster  relatives,  153 
France,  98 

Frankfort  Hospital,  49 
Frankfort,  Jewish  insane  in,  49 
Free    Synagogue,     social    service 

dept.,  179,  192,  193,  194,  195,  234 

General  paralysis,  68,  7Z,  78,  122, 
142,  143,  145,  146,  157,  162,  219, 
228 

General  paralysis,  juvenile,  7^,  77 

General  paralysis,  prognosis  of,  75 

General  paralysis,  treatment  of,76 

Germany,  98 

Germany,  insanity  in,  49 

Gesell,  Prof.  Arnold,  231 

Gestation,  94 

Girls,  adolescent,  237 

Girls,  wayward,  105 

Glands,  internal,  87 

Greece,  98 

Grotius,   188 

Hallucinations,  73 

Hebrew  Infant  Asylum,  185 

Hebrew  Orphan  Asylum,  1S5 

Hebrew  Sheltering  Guardian  So- 
ciety, 185 

Hemorrhage,  cer<;bral,  80 

Heredity,  63,  64,  65,  82,  84,  86,  89, 
90,  150,  173 

Heredity,  neuropathic,  83 

Homeopathic  asylum,  26 

Homes,  convalescent,  236.  237,  240 

Homicide,  36,  155 

Hospital  Development  Commis- 
sion, 44,  45,  115 

Hospital,  general,  119,  140,  177, 
188,  189,  190,  194,  240 

Hospital,  municipal,  116 


Hospital,    psychopathic,    ro8,    132. 

239 

Hospital  social  service,  191 
Hospitals,  special,  194,  240 
House  of  Refuge,  105 
Hudson   Lunatic  Asylum,   20,   25, 

Humanitarianism,  era  of,  15 
Hydrotherapeutic  apparatus,    147 
Hypomanic,  91 
Hysteria,  91,  221 
Hysterical  episode,  91 

Imbecile,  104 
Immigrants,  97,  156,  164 
Immigration,  72,,  loi 
Immigration,  Jewish,  .74,  98 
Immigration   Law,   lOi 
Improvement,  rate  of,   135 
Indifference,  era  of,  15 
Indigent  insane,  25,  148 
Industries,  hospital,   122,   125 
Infection  exhaustion,  81 
Influenza,  81 
Injuries,  head,  69 
Insane,  acute,  24,  25 
Insane,  borderline,  188 
Insane,  chronic,  24,  28,  29,  33,  156, 

168 
Insane,  classification  of,  22 
Insane,  criminal,  18 
Insane,  curable,  33 
Insane,  dangerous,  19 
Insane,  disorderly,   17 
Insane,  immigrant   99 
Insane,  social  care  of,  132 
Insanity,  causation  of,  20,  62,  6f 
Insanity,  definition  of,  60,  61,  133 
Insanity  Law,   173 
Insanity,  recoverable,   152 
Insomnia,  85 
Institute,  psychiatric,  236 
Involutional  melancholia,  84 
Inwood  House,  105 

Jails,  insane  in,  60 

Jewish  population,  so,  53 

Jewish  psychopathic  cases,  48 

Jews,  130,  191,  240 

Jews,  alcoholic,  53,  80 

Jews,  distribution  of,  50 

Jews,  insanity  among,  48,  49,   50, 

SZ,  98,  127,  131,  132,  136,  137 
Jews  in  New  York,  51 
Jews,  persecution  of,  50 


246 


INDEX 


[38S 


Judges,  County,  22 

Kings  County,  23,  24,  30,  32,  33 
Kings  County  Hospital,  53,  108 
Kings  Park  State  Hospital,  135 
Kitchens,  kosher,  131 
Kraepelin,  Emil,  62,  77,  81.  85,  in 

Lactation,  94 

Legislature  of  New  York,  39,   184 

Licenses,  marriage,  169 

Lombroso,  49 

London,  insane  in,  49.  117 

Lues,  78 

Manhattan  Island,  39,  45 
Manhattan  State  Hospital,  34,  39, 

53,   121,   122,    126,  127,   128,   129, 

135.  139,  143.  150,  170,  178 
Manic  depressive  insanity,  81,  82, 

83,  84,  86,  99,  122,  131,  144,  145, 

147,  152,   178,  183,   196.  198,  200, 

228 
Marcy,  115 
Marcy,  Gov.,  21 
■Marriage    Law,    modification    of, 

168 
Massachusetts    General    Hospital, 

190 
Matteawan  asylum,  23 
Maudsley,  Dr.  Henry,  61,  117,  133 
Mendel's  Law,  64 
Meningitis,  73 

Mental  defective,  105,  193,  220 
Mental     Defectives,     Commission; 

of,  107 
Mental  Deficiency  Law,  107 
Mental   diseases,   classification  of, 

69,  70 
Mental  hygiene,  132,  137,  140,  173, 

179,  189,   191,   192,  193,  227,  229, 

239.  241 
Michigan,  it8 
Middletown     State    Hospital,    26, 

126 
Mineola  asylum,  33 
Mohansic  hospital,   115 
Monroe  County    Asylum.    24,    ^o, 

32 

Narcotics,  80 
Native  born,  70,  113 
Needle  trades,  125 
Nervous  disorders,  193 
Neuroses,  91,  195,  231 


New  York  City,  43,  48,   no,   115, 
132,  137,  140,  191,  228,  235,  23^ 
239,  240 
New  York  City  Hospital,  16 
New  York  County,  23,  24,  30,  32, 

34,  51 

New  York  State.  16,  no,  118,  09, 
121,  168,  190,  233 

New  York  State  Inebriate  Asy- 
lum, 28 

New  York  State  Hospital  Com- 
mission, 100 

Nurses,  113,  120,  126,  130,  131,  154, 
179 

Nurses  Training  School,  37 

Observation  period,  115,   116,   117, 

xi8 
Occupational  therapy.  121 
Occupations,    112,    121,    123,    124^ 

125.  137,  151,  156,  178,  182,  183 
Ogdensburg,  28 
Ordronaux,  John,  27 
Organic  nervous  disease,  73 
Organization,  relief,  158,  161,  162 
Orphan  asylums,  159,  185,  194 
Orphans,  161,  162,  165 
Orr,  Florence  I.  64 
Out-patient,  38,  169,  170,  189.  190, 

191 
Overcrowding,  84,  91,  113,  114,  115,. 

120,  121,  126,  131,  146,  154,  181 

Paranoid  Condition,  214,  216,  217, 

228 
Parole,  138,  139,  152,  169,  172,  174, 

177.  178,  179,  180,  182,  189 
Parole  agents,  149 
Parole  system,  169,  170 
Phipps  Institute,  239 
Prevention,  137,  170,  193,  229.  231, 

238 
Prisoners,   153 
Propaganda,  193 
Psychiatric  institute,  236 
Psychiatric     social     worker,     193, 

228,  229 
Psychiatrist,  138,  140.  179,  192,  234 
Psychology,  179,  192,  239 
Psychoneuroses.   194.  228,  229 
Psychopathic  hospital,  229 
Puberty,  85,  233 
Public    Welfare,    Department    of, 

166.   185 
Puerperal  state,  69 


389] 


Readjustment,  152,  176,  177,  186 
Readmissions,    126,   127,    128,    129, 

130,  131,  140 
Reception  hospital,  38,  39,  40,  43 
Recommitment,  114,  116 
Recoveries,  113,  119,  130,  133,  ^2>7, 

143,  144,  229 
Recovery,  retardation  of,  153 
Red  Cross,  American,  159,  167 
Recreation,  174,  176,  186,  196 
Relapse,  131,  137,  182 
Relatives,  foster,  153 
Relief  agency,  161,  184,  194 
'Relief,  financial,  150,  184 
Research,  iii,  112,  113,  115 
Restraint,  physical,   147 
Retreats,  119 
Revenge,  era  of,  15 
Revolutionary  War,  16 
Richmond  Borough,  53 
iRivercrest,  103 
Rochester,  24 
Rosanoff,  A.  J.  64 
Roumania,  98 
Russia,  98 

Salvarsan,  yy,  78 

Sanatoria,    private,    loS,    119.    155, 

194.  -239 
Schoharie  County,  52 
Schools,  reconstruction,  232 
Semitic  races,  49 
Senile  psychosis,  70,  126,  142,   143, 

145 
Senility,  69,  98,  105,  122 
Sheet,   restraining,   147 
Sichel,  Max,  49 
Social   Service,   140,    179,   185,   189, 

193,  227,  228,  229 
Social   worker,    57,    138,    140,    169, 

170,   171,  227,  235 
Soldier  insane.  52 
Spain,  98 

Speech  defective,  2:^2 
Spitzka,  Edward  C,  50 
Spoils  system,  T,y 
Spring  Hill  Sanatorium,  103 
State  architect,  47 
State  care,  30 

State  Care  Act,  25,  32,  35,  34,  35 
State  hospitals,  108,  116,  126,  128. 

129,  134,  135,  138,  194 
State  Hospital  Commission,  ^7,  38, 

III,   139 


INDEX 


247 


'St.  Lawrence  State  Hospital,  28 

iState  Lunacy  Commission,  38 

Stress,  84,  97 

Stupor,  144 

Suicide,  36,  85,  106,  107,  155 

Superintendent  of  poor,  22,  28 

Supervisors,  Board  of,  118 

Survey,  174,  180,  182 

Switzerland,  98 

Syphilis,  68,  y2,  78,  90,  105,  I57 

Teachers,  123,  181 
Teacher-nurses,  22,2 
Teutonic  race,  insanity  among,  50 
Therapy,    occupational,    121,    122, 

125 
Thomson,  J.  Arthur,  65 
Throop,  Gov.,  19,  21 
Tombs,  The,  106 
Treatment,  126,  135,  142,  160,  173, 

193,  194,  232 
Truant  school,  105 
Tuberculosis,  81 
Tumor,  y:^ 
Turkey,  98 
Typhoid,  81 

United  Hebrew  Charities,   184 

United  States,  34,  iii 

United  States  Census,  94,  96 

United  States  Dept.  of  Commerce, 
49 

United  States  Immigration  Ser- 
vice, 102 

Utica,  115 

Utica  (State  Hospital,  22,  24,  25 

Venereal  diseases,  74 
Vienna,  insane  in,  49 
Visits  to  patients,  139,  153 
Voluntary  patients,  58 

Ward's  island,  23 
Warren  County,  52 
Wasserman  test,  yy,  163 
Waverly  House,  104 
White,  Dr.  Samuel,  20,  21 
White,  Dr.  WiUiam  A.  60 
White  Plains,  122 
Willard  Asylum,  25,  29 
Willard,  Dr.  Sylvester  D.  25 
Workshop,  model,  236,  237,  238 

Yale  University,  231 


VITA 

Jacob  Alter  Goldberg,  born  in  New  York  City,  June 
10,  1890.  Educated  in  New  York  City  public  schools; 
graduated  Townsend  Harris  High  School ;  College  of  the  City 
of  New  York,  A.B.,  February,  19 13.  Entered  Columbia 
University  in  September,  1914,  as  a  graduate  student 
under  the  Faculty  of  Political  Science;  received  A.M. 
degree  June,  1916;  title  of  essay  submitted  for  master's 
degree:  Drug  Addiction  m  a  Social  and  Legislative 
Problem.  Continued  at  Columbia  University  to  Jan.  1921. 
Special  student  Union  Theological  Seminary,  1916-1917. 
For  a  number  of  years  in  charge  of  a  social  settlement; 
taught  in  the  evening  schools;  district  supervisor  of  lec- 
tures ;  inspector  of  dance  halls,  theatres,  etc. ;  hospital  social 
service  worker;  associated  with  Drs.  Stephen  S.  Wise  and 
Sidney  E.  Goldstein  in  the  religious,  social  and  educational 
work  of  the  Free  Synagogue.  Since  19 17,  secretary  of 
the  mental  hygiene  division,  social  service  department,  Free 
Synagogue,  At  Columbia  University  studied  under  Profs. 
Lindsay,  Devine,  Giddings,  Seager,  Barnett,  and  Chaddock. 

249 


'-13 


SOCIAL  ASPECTS  OF  THE  TREATMENT 
OF  THE  INSANE 

Based  on  a  Study  of  New  York  Experience 


BY 

JACOB  A.  GOLDBERG,  A.  M. 


SUBMITTED  IN  PARTIAL  FULFILMENT  OF  THE  REQUIREMENTS 
FOR  THE  DEGREE  OF  DOCTOR  OF  PHILOSOPHY 

IN   THE 

Faculty  of  Political  Science 
Columbia  University 


MW9    1922 


NEW  YORK 
192I 


